How Cystic Fibrosis Research Helped Establish the 6-Foot Rule for Physical Distancing

By the bioMérieux Connection Editors

May is National Cystic Fibrosis (CF) Awareness Month in the United States, and presents an excellent opportunity to learn more about a complex disease that currently affects around 30,000 people in the US. CF is a genetic disease that causes build-up of thick mucus in the lungs. This mucus allows bacteria to thrive and easily multiply—thus people with CF are highly susceptible to lung infections.

The COVID-19 pandemic has understandably caused concern for groups of people with underlying health conditions such as CF. While there isn’t clear evidence that people with underlying health issues are at a higher risk of contracting a COVID-19 infection, there is indication that these members of our community are at a greater risk of developing serious illness from COVID-19 if they become infected. Experiences from recent pandemics illustrate this risk—during the 2009 influenza pandemic, the H1N1 virus greatly impacted patients with CF and was associated with severe complications.

Due to these serious risks, the CDC outlines extra precautions for those at higher risk of severe illness, including people with CF. These precautions are intended to be taken on top of the CDC’s base recommendations for protection, which include avoiding close contact with people who are sick, staying home as much as possible, and remaining at a distance from others. In this regard, the general public can learn from the CF community, who have been following their own 6-foot rule for many years.

Where Did the 6-Foot Rule Come From and Why Is It Important?

In the early 1980’s, doctors and epidemiologists started researching the presence of a group of bacteria collectively known as Burkholderia cepacia (B. cepacia) in the CF community. Pseudomonas aeruginosa (P. aeruginosa) was already considered to be particularly dangerous for patients with CF, contributing to as many as 80% of chronic infections, but autopsy data provided a surprising finding: the presence of B. cepacia.

The CDC conducted critical research and found that B. cepacia was present in 18% of people with CF and caused serious disease—additionally, the mortality in B. cepacia-infected CF individuals after only 90 days was 20%. As a comparison, mortality for CF patients infected with P. aeruginosa generally occurred years or even decades after the initial infection. This troubling data was compounded by the fact that B. cepacia complex is frequently resistant to antibiotics, severely limiting treatment options.

Additional research determined that social contact among people with CF was a major mode of transmission and acquisition of B. cepacia complex. This transmission is commonly referred to as cross-infection—one person with CF passing their unique bacteria, including P. aeruginosa and B. cepacia, on to someone else who has CF. Due to these findings, in 2003, the Cystic Fibrosis Foundation published infection control guidelines that remain the standard of care in the CF community.

The guidelines set forth physical distancing recommendations, which include the “6-foot rule”—people with CF should stay 6 feet away from anyone who is sick and any other individuals who have CF, to avoid cross-infection. Six feet (or 2 meters) is generally the distance that large infectious droplets will spread from person to person after a cough or sneeze. While this meant that the CF community was not able to interact with each other as they had been—summer camps were closed, support groups cancelled, friends not able to gather—the distancing has proven to be extremely effective. The prevalence of B. cepacia complex infection among people with CF was 18% in the early 1980’s, but in 2017, the prevalence was at only 2.4%. The person-to-person spread has been limited, and it is now assumed that most acquisition of B. cepacia is from the natural environment.

Adapting to Physical Distancing: Lessons from the CF Community

The world at large is having to abide by social distancing orders amidst COVID-19, which is something that individuals with CF have been experiencing to some degree for much of their lives to protect their health. In a recent article for the CF Community Blog, Kristin Dunn, an adult with CF, states, “This is a temporary circumstance for everyone during the COVID-19 global pandemic… But, it’s a forever reality for all of us living with cystic fibrosis.”

Society can learn from the CF community that public health should always come first, and that there are innovative solutions for connecting. Dunn goes on to give meaningful advice for those struggling through quarantine: “We all can work together meaningfully, celebrate together, and connect emotionally without ever being in the same room.”


Opinions expressed in this article are not necessarily those of bioMerieux, Inc.

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