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P ro c e e d in g s o f th e W o rk s h o p o n E n g in e e rin g C o n tro ls fo r P re v e n tin g A ir b o r n e I n f e c tio n s in W o r k e r s in H e a lth C a re a n d R e la te d F a c ilitie s

US. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service f Centers for Disease Control and Prevention V National Institute for Occupational Safety and Health

P ro c e e d in g s o f th e W o rk s h o p o n E n g in e e rin g C o n tro ls f o r P re v e n tin g A ir b o r n e In fe c tio n s in W o r k e rs in H e a lth C a r e a n d R e la te d F a c ilitie s

Edited by: PHILIP J. BEERBACM, M.E. MORTON LJPPMANN, PhJ).

July 14-16,1993 Cincinnati, Ohio

US- DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Centers for Disease Control and Prevention National Institute for Occupational Safety and Health

DISCLAIMER

Sponsorship of this workshop and these proceedings by NIOSH does not constitute endorsement of the views expressed or recom mendation for the use of any commercial product, commodity or service mentioned. The opinions and conclusions expressed in the keynote and plenary papers are those of the authors and not necessarily those of NIOSH. The research recommendations are not to be considered as final statements of NIOSH policy or of any agency or individual who was involved. They are intended to be used in advancing the knowledge needed for worker protection. This document is in the Public Domain and may be freely copied or reprinted.

Copies of this and other NIOSH documents are available


from :

Publication Dissemination, DSDTT National Institute for Occupational Safety and Health 4676 Columbia Parkway Cincinnati, Ohio 45226 (513) 533-8573 (fax) For information -on other occupational safety and health problems, call 1-800-35-NIOSH

DHHS (NIOSH) Publication No. 94-106

TA BLE O F C O N TEN TS

TABLE OF CONTENTS ACKNOWLEDGMENTS EXECUTIVE SUMMARY WORKSHOP PARTICIPANTS

iii iv v xxi

WORKSHOP OPENING AND CHARGE Richard A, Lernen Philip J. Bierbaum Morton Lippmann
KEYNOTE ADDRESSES

1 2 6 10
13

Theodore C. Eickhoff Perspectives on Airborne Infection A rthur E, W heeler A Perspective of Ventilation


PLENARY ADDRESSES

15 35
49

Eugene C* Cole Aerosol Characterization James M. Melius Source Characterization and Control Georgeann Bum s Building Designs Richard D. Hermans and Andrew J. Streifel Ventilation Designs
RESEARCH RECOMMENDATIONS

51 73 93 107 147 149 155 162 168 173 175 181

Aerosol Characterization Source Characterization and Source Control Building Designs Ventilation Designs
SYNOPSIS

Morton Lippmann Philip J* Bierbaum

iii

ACKNOWLEDGMENTS

In addition to the keynote and plenary paper presenters, panel moderators and rapporteurs, panel members, and program com mittee members we wish to thank the following NIOSH employ ees for their diligent effort in the conduct of this workshop and the preparation of this document: Laurence J, Doemeny* Ph,D,, scientific coordinator; Rosalynd J. Kendall, who served as our administrative coordinator for the workshop and who "did it all" ; Maggie A, Ivory, Heather K, Houston, and Deanna L, Elfers, who served as Ms. Kendall's assistants, Kevin Brown, Karen Frost, Juanita Nelson, and Patricia Lovell, who served as assistants during conference panel sessions; Theodore F. Schoenbom, who served asthe coordinator for the preparation ofthis document; and Vivian K. Morgan, Janice M . Huy, Charlene B. Maloney, and Shirley M. Carr, who served as team members for our printing and publication activities.

t i v

Executive Summary
EXECUTIVE S U M M A R Y

The National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC) convened a workshop during July 14-16, 1993, in Cincinnati, Ohio* to develop a national research strategy on engineering controls for preventing airborne infections in workers in health care and related facilities. The purpose of the workshop was to: Review the nature and extent of airborne transmis sion ofinfections in workers in health care and related facilities. Review current data and new findings regarding the engineering control of airborne infections that may have relevance to occupational exposures in health care and other institutions. Identify knowledge gaps that might be filled by directed research. Recommend a national research agenda that, if imple mented, would close the gaps and permit reliable recommendations for protecting workers.

Approximately 400 individuals attended the workshop, including 125 from governmental agencies, 40 from academia, 150 from health care and related facilities, 25 consultants, 30 from labor organizations and 40 from the insurance industry, architectural firms, etc. The mix of expertise included infection control practitioners, industrial hygienists, physicians, nurses, epidemi ologists, engineers, architects, front line healthcare professionals and other workers from health care facilities. Two keynote papers were presented: Perspectives on Airborne Infections in Health Care Facilities and A Perspective of Ventilation for Health Care and Related Facilities. These two papers provided the workshop participants and attendees with a general overview ofthe issuesofairbornetransmission ofinfections

Executive Summary and engineering (ventilation) controls for preventing such transmissions. Four plenary papers were presented, each addressing a specific aspect of preventing airborne infections in workers. The four plenary presentations covered: * Aerosol characterization. Source characterization and source control. Building designs. Ventilation designs.

Panels ofexperts in the four areas, using the information presented in the plenary papers and the background information from the keynote papers, focused on the development of a national research agenda. These Proceedings, then, serve as a report to the Nation based on the interaction and discussions that occurred during the workshop among occupational health specialists, infection con trol specialists, engineers, architects, academicians, administra tors and workers. This document w ill provide a lasting record of the excellent keynote and plenary papers that were presented* and w ill focus research on the needs that were identified for worker protection. These Proceedings provide the reader with the follow ing information: * * * An executive summary which highlights the findings from the workshop. Introductory and summary comments from the work shop co-chairs. The two keynote and four plenary papers which served as the basis for the panel discussions. The research recommendations which resulted from the panel deliberations.

Executive Summary HIGHEST PRIORITY RESEARCH NEEDS It was recognized that the ''engineering research needs identified in this workshop were not unusual for the occupational/environ mental health and infection control fields. However certain general issues and priority areas were identified by all four panels. These are summarized as follows: * The need to be able to characterize and assess the various properties of the aerosols (e.g., size, shape, aerodynamic properties, survivability). The need for sampling andanalylical methods for use in determining exposure levels and efficacy of controls. The need to be able to rapidly identify infectious sources (e.g*, patients, workers, contaminated surfaces, etc.) sothat appropriate control technique(s) can readily be applied. The need to determine the efficacy of various control techniques (administrative and engineering controls) individually and/or collectively. The need for criteriaand methodologies for designing (new and retrofit) inpatient isolation and intensive care rooms, surgical suites, emergency rooms, waiting rooms, etc. The need for special design criteria and control techniques to protect worker groups outside of the usual definition of health care worker (e.g., workers in social service settings and correctional settings and maintenance and hazardous waste workers) and for high risk workers, (e.g., immunocompromised individuals).

Also, it was recognized by all participants that there is a need to assemble all the relevant knowledge and expertise that is available in the infection control practitioner community, the occupational health community and engineering/architecture community to solve this workplace problem. Interdisciplinary interaction needs to be stimulated for consolidation of known
ix

Executive Summary information and identification of residual research needs. The knowledge that already exists among the professional and worker communities, mentioned above, needs to be collected and shared so as to provide direction and solutions to immediate problems. There is a considerable amount of knowledge that exists but is not being applied; a universal data base is needed for all to use. The various components of the recommended research agenda do not have to be conducted in sequence. However, it should be noted that without (1) better exposure assessment tools for estimating dose, (2) better knowledge about exposure levels, and (3) better knowledge about the relevancy of exposure levels to disease risk, there w ill be limitations in the ability to prevent airborne transmission of infectious agents. Implementation of this research agenda should not postpone efforts to implement prevention strategies that are now available and feasible. SUMMARY OF RESEARCH NEEDS The major research needs in each of the four program areas that were discussed at the workshop are highlighted below. Aerosol C haracterization

Characterize infectious aerosols as they emerge from the


source To validate laboratory studies with test organisms, the carrier particles need to be matched to realworld particles.

Assess physical properties such as shape, size, and aerody namic properties
To develop sampling and analytical methods, the size, shape, and viability of infectious agents need to be understood.

E x e c u tiv e Su m m a ry

Improve existing or develop new sampling and analytical methods


T o control exposure, to evaluate controls, or to identify potentially hazardous conditions, technolo gies for rapidly a n d reliably assessing the presence a n d quantity o f infectious agents are n e e d e d

Study the microbial ecology of infectious agents in the environment


Factors that regulate grow th , including o r g a n i s m r esponse to drugs, disinfectants, a n d ultraviolet light, pr o vi de insight into control strategy options. T h e ability o f o r g a n i s m s to survive in s a m p l e collection devices also m a y represent a significant p r o b l e m , F o r viable s a m p l i n g m e t h o d s , the o r g a n i s m s m u s t ma intain their ability to r e p ro du ce a n d g r o w following impaction, i m p i n g e m e n t , a n d p o s sible desiccation o n a filter or other s a m p l i n g surface.

Select model pathogens for use in testing sampling meth ods and controls
T h e r e is a n e e d to identify a n d select m o d e l p atho g e n s for use in testing s a m p l i n g m e t h o d s a n d control technologies. M o d e l s for bacteria, fungi a n d viruses m a y b e needed. P a t h o g e n s o f c o n c e r n that require m o d e l o r g a n i s m s include, b u t are not limited to Af. tuberculosis, Legionella , A sp e rg il

lus, a n d rubella, influenza, varicella, adenoviruses,


a n d measles.

Evaluate control technologies, individually and in combi nation


T o i m p r o v e o n infection controls, research o n the effectiveness o f various control technologies,

xi

E x e c u tiv e Su m m a ry
individually a n d in c o m b i n a t i o n is needed. Control strategies currently p r o p o s e d include ventilation (local a n d general), H E P filtration, ultraviolet germicidal irradiation, a n d respiratory protection. Efficacy o f these techniques n e e d s to b e proved.

Evaluate the performance of filtration control


T h e efficacy o f filtration, including H E P A filters, a n d the u s e o f respiratory protective e q u i p m e n t n e e d s to b e assessed. T h e penetration a n d viability o f o r g a n i s m s as th ey pass thr o ug h filters n e e d s to b e evaluated.

Characterize and assess resuspended aerosols


T h e survivability o f infectious agents o n surfaces, clothing, b e d d i n g materials, etc., w h i c h m a y be c o n t a m i n a t e d wi t h infectious agents that h a v e the potential to b e re-aerosolized, need*; to assessed. Research a ls o s h o u l d focus on fungi for aerosclization f r o m surface growth.

S o u r c e Characterization a n d S o u r c e Control

Identification of infectious sources


T h e m a j o r source for the transmission of airborne infections in health care a n d related facilities is infected persons. T h e bacteria or viruses m a y b e e x h a l e d as the p e r s o n talks, c o u g h s , or sneezes. M i c ro bi a l conta m in at io n o f ventilation systems, w h i l e a contributing factor in potential n o s o c o m i a l infections in i m m u n o c o m p r o m i s e d persons, h as not b e e n c o m m o n l y reported in w o r k e r s as a result of work-related exposures. importance. Thus, prompt identification o f infectious indi viduai s is o f u t m o s t

x ii

E x e c u tiv e Su m m a ry

* Epidemiology and surveillance studies


T h e a d e q u a c y o f infectious disease surveillance s y s t e m s (i.e., identification o f patients k n o w n to b e infected) in local a n d state health dep a rt me nt s n e e d s to b e evaluated. A prospective surveillance s y s t e m for tuberculosis skin test conversions in health care facilities (e.g., possibly Na ti on a l N o s o c o m i a l Infection C o n t r o l S y s t e m - b a s e d [ N N I S - b a s e d ] ) n e e d s to b e established. F o l l o w u p studies o f e x p o s e d w o r k e r s n e e d to b e c o n d u c t e d to better u n d e r s t a n d the sources o f airborne infections a n d the efficacy o f current control procedures. E p i d e m i o l o g i c studies n e e d to b e t u b e r c u l i n s k i n test conducted of w o r k e r

c o nv ersions in related facilities" to identify the risk o f acquiring T B infection in these settings.

Engineering and procedural controls


M a n y o f the source control m e t h o d s u se d to prevent airborne transmission o f infectious diseases involve procedural as well as engineering m e t h o d s o f controlling exposures. T h e m a j o r engineering a n d procedural control research included the n e e d to: 1. E va l u a t e existing a n d d e v e l o p novel control m e t h o d s for special h i g h risk procedures s u c h as s p u t u m induction b r o n c h o s c o p y , patient transportation. 2. Ev aluate efficacy o f recirculation units (i.e., in duct air filtration a n d ultraviolet germicidal irradiation [UVGI]). 3. Ev aluate auxiliary exh a us t units (i.e., in-duct or inr o o m * ventilation s y s t e m s us ed to a u g m e n t general ventilation) via field evaluations a n d e pi demiologic studies. 4. D e v e l o p p e r f o r m a n c e criteria a n d testing protocols for portable, stationary, a n d in-duct hi gh efficiency

x iii

E x e c u tiv e Su m m a ry
particulate air ( H E P A ) a n d ultra-low penetration air ( U L P A ) filtration units. 5. 6. E va luate p e r f o r m a n c e a n d pr o vi de information o n available fitters a n d filtration systems; E va luate personal safety a n d efficacy issues of U V G I disinfection o f air (i.e., upper-air a n d in-duct irradia tion). 7. E va luate the a d e q u a c y o f the W el ls-Riley equation for estimating the risk o f acquiring tuberculosis in fection a n d m o d i f y the equation, if necessary; 8. E va luate airflow patterns within the r o o m s a n d their i m p a c t o n local variation o f infectious aerosol c o n centration within die r o o m s . 9. D e v e l o p a national respirator task force to discuss a n d m a k e r e c o m m e n d a t i o n s o n the types a n d use of respirators b y patients, health care w o r k e r s a n d visitors. JO. C o n d u c t ha za r d asse ss me n t o f m e d i c a l w a s t e dis posal w o r k e r s at health care a n d m e d i c a l w a s t e dis posal facilities.

Education
T raining a n d education are important factors in a n infection control p r og r a m . Evaluation a n d revi sion of current materials a n d techniques are n e e d e d to m e e t the objective o f preventing the transmis sion o f all infectious agents. T h e u s e o f these materials s h o u l d b e directed t o w a r d practioners in infection control, industrial hygiene, a n d facilities engineering; a n d also t o w a r d patients, clients, w o rkers, inmates, a n d others.

Recommendations not otherwise classified


T h e s e r e c o m m e n d a t i o n s did not fall u n d e r o n e o f the other four m a j o r areas o f research. Issues w h i c h n e e d to b e a d d r e s s e d inc lu d e special

x iv

E x e c u tiv e S u m m a ry
considerations of individuals c o v e r e d u n d e r the Americans w i t h Disabilities Act (ADA), c o m p l i a n c e w i t h infection control procedures, a n d overall m a n a g e m e n t of a n infection control program. Building D e s i g n s

Interim control measures


I m m e d i a t e interim m e t h o d s n e e d to b e d e v e l o p e d for i m p r o v e d w o r k e r a n d patient protection until n e w construction, renovation, and/or other initia tives are d e v e l o p e d for med ic al centers a n d related facilities s u c h as h o m e l e s s shelters, a m b u l a t o r y care, m e t h a d o n e clinics, etc.

Genera] facility planning


M e t h o d o l o g i e s n e e d to b e d e v e l o p e d to calculate the n u m b e r of inpatient acute a n d intensive care infectious isolation r o o m s , b o t h o n a regional health p l anning basis a n d also o n a hospital or n e t w o r k - w i d e basis. Also, m e t h o d o l o g y n e e d s to b e established to identify hospital b a s e d ancillary service n e e d s a n d alternate care delivery sites. In addition, criteria a n d p r o g r a m m a t i c n e e d s for the layout a n d location of infectious isolation a n d related facilities n e e d to b e developed.

Isolation suite anteroom design


It s h o u l d b e d e t e r m i n e d w h e t h e r a n t e r o o m s are necessary in isolation suites, a n d h o w t he y sho ul d b e d e s i g n e d a n d physically located in regard to the isolation suites.

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E x e c u tiv e S u m m a ry

* Existing buildings
Strategies n e e d to b e d e v e l o p e d for converting existing buildings to m e e t the criteria a n d p r o g r a m m a t i c n e e d s o f protecting health care w o r k e r s a n d patients f r o m airborne infections.

* Treatment room design


T h e appropriate design criteria a n d t e ch no lo g y n e e d to b e d e t e r m i n e d for areas w h e r e s p u t u m induction, administration o f aerosolized m e d i c a tions, a n d other h i g h risk proc ed u re s are pe r f o r m e d , s u c h as booths, specialized r o o m s or e n closures ( b r o n c h o s c o p y a n d p e n t a m i d i n e a d m i n istration).

Long-term treatment/isolation facilities


P e r f o r m a n c e criteria n e e d to b e d e v e l o p e d for designing facilities for patients h a v i n g a l o n g t e r m n e e d for treatment or isolation (e.g., n e e d for living space, recreational facilities, m o v e m e n t a r o u n d the facility),

* Ancillary service and other facilities


T h e effect o f p r o l o n g e d or repetitive contact w i t h h i gh risk clients o n the health o f health care and/or social service w o r k e r s s h o u l d b e studied. Also, the probability of w o r k e r s a n d clients acquiring air b o r n e infections in o v e r c r o w d e d conditions (e.g., places o f a s se mb ly , transportation, h o m e l e s s shel ters, d a y r o o m s , etc.) s h o u l d b e studied. In addi tion design criteria for p r o l o n g e d contact waiting spaces (e.g.* initial patient screening, e m e r g e n c y d e p a r t m e n t holding areas, public waiting spaces, etc.) s h o u l d b e developed-

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E x e c u tiv e Su m m a ry

Ventilation Designs
Pathogen generation rates and concentration control levels
T h e application o f effective control t e c h no lo gy requires k n o w l e d g e o f the level o f c o n t a m i n a n t b e i n g generated a n d a concentration level limit. T h e s e levels are not well infectious o r g a n i s m s

known

for airborne

and n e e d

to b e determined.

Identification of ventilation rates and distribution of gen eral ventilation airflow


R e s e a r c h is n e e d e d to d e t e r m i n e the feasibility o f utilizing the We lls-Riley equation to establish appropriate ventilation rates. T h e effect o f airflow level in reducing c o n t a m i n a n t levels in a space n e e d s to b e researched. Detailed information is n e e d e d o n the effects o f air distribution, s u c h as c o m p a r i s o n o f d i s p l a c e m e n t vs, dilution ventila tion.

Local exhaust ventilation


R e s e a r c h is n e e d e d to d e te r mi ne h o w to apply o p e n type h o o d s to treatment p r o c e d u r e s s u c h as bronchoscopy.

R e s e a r c h is n e e d e d to d e te rm in e efficacy o f por table cleaning devices a n d to d e v e l o p standards for m a i n t e n a n c e a n d operation o f b o t h patient enclosures a n d portable cleaning devices.

Filtration
Research is n e e d e d to determine the application a n d effectiveness o f filtration o f various infectious dis ease organisms, a n d the safety aspects o f filter m a i n tenance.

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E x e c u tiv e Su m m a ry

* Containment
R e s e a r c h is n e e d e d o n de t ermining the p ro p e r airflow bal an ce in a r o o m to achieve a d e q u a t e levels o f negative pressure a n d the n e e d for ante r o o m s ( a n d a n t e r o o m airflow balance).

Maintenance guidelines and performance monitoring


T h e r e is a n e e d to d e v e l o p m a i n t e n a n c e guidelines a n d s y s t e m m o n i t o r i n g techniques f o c u s e d o n health care ventilation sy s te ms w h i c h c a n b e readily i m p l e m e n t e d to prev en t s y s t e m b r e a k d o w n .

* Ventilation control system design


R e s e a r c h o n h o w to properly operate a n d maintain facility ventilation s y s t e m s thro ug ho u t a n entire facility is needed.

* Side effects of engineering controls


A study o f the side effects o f existing a n d n e w e ngineering controls s ho u l d b e c o n d u c t e d to iden tify accep ta nc e p r o b l e m s a n d to r e c o m m e n d c or rective p r o c e d u r e s w h i c h will aid in acce pt a nc e o f the control.

Role of ultraviolet irradiation in infection control


R e s e a r c h s ho u l d b e c o n d u c t e d to evaluate the efficacy o f

UV irradiation

in killing airborne in

fectious o r g a n i s m s a n d to d e v e l o p parameters (dose response) to permit its effective application. R e c o m m e n d a t i o n s also n e e d to b e d e v e l o p e d for safe operation a n d m a i n t e n a n c e of the tems.

UV

sys

x v iii

E x e c u tiv e S u m m a ry S a m p lin g a n d te s tin g m e th o d s


T h e r e is n e e d to d e v e l o p s a m p l i n g a n d testing m e t h o d s w h i c h will pr o vi de real-time or ne a r real t i m e determination o f c o n t a m i n a n t levels. T h e r e also is a n e e d to identify a n o n - p a t h o g e n i c surro gate for testing a n d evaluation o f control me t ho ds .

Interdisciplinary communication
T h e feasibility o f a health care control t e c hn ol og y data base, including control solutions f r o m a w i d e r a n g e o f areas s ho u l d b e studied and, iffeasible, b e developed.

Comprehensive control study


Co nt ro l o f airborne infectious disease is d e p e n dent o n the application o f a n u m b e r o f control m e t h o d s a n d w o r k practices. A control study should b e p e r f o r m e d in the health care setting to validate the c u m u l a t i v e effect o f a c o m p r e h e n s i v e applica tion o f control proce du r es (e.g., ventilation, isola tion, respiratory protection, administrative p r o c e dures, etc.).

Philip

J. B i e r b a u m ,

M E.

M o r t o n L i p p m a n n , Ph.D., C I H Co-Chairs

W o rk sh o p P a rtic ip a n ts

P R O G R A M C O M M IT T E E

Philip J. Bietbaum, M.E. Co-Chair Director, Division of Piysteal Sciences and Engineering National Institute for Safety and Health Centers forDiseaseControland Prevention Cincinnati, O H 45226 Morton Lippmami, Ph.D. Co-Chair and Professor, Nelson institute of Environ mental Medicine N e w York University Medical Center Tuxedo, N e w York 10987 William K- Borwegtn, M.P.H* Director Occupational Safety and Health Department Service Employees International Union Washington, D C 20005 Douglas S. Erickson, B.S.A.E. Director, Design and Construction American Hospital Association Chicago, IL 60611 Robert C. Good, Ph.D. Branch Chief Respiratory Disease Branch Division of Bacterial and Mycotic Dis eases National Center for Infectious Diseases Center* forDisease Control and Prevention Atlanta, G A 30333 Frank J , Hear], M.S.Ch.E., P.E. Chief,Environmental Investigations Branch Division of Respiratory Disease Studies National Institutefor Occupational S afety and Health Centers forDisease Controland Prevention Morgantown, W V 26505

Richard D. Hermans, B.M.E., P.E, GeneralManagerpadUti Operations Mid Maintenance St. Pani Public Schools St Paul, M N 55108 Charles R. Horsburgh, M . D Medical Epidemiologist Division of HIV/AIDS National Center for Infectious Diseases Centos for Disease Control and Prevention Atlanta, G A 30333 Robert Hughes, M.S., P.E. Chief. Control Section 3 Engineering Control Technology Branch Division of Physical Sciences and Engineering National InstituteforOccupational Safety and Health Centers for Disease Control and Prevention Cincinnati, O H 45226 William R_ Jarvis, M.D. Chief,Investigationand Prevention B ranch Hospital Infections Program National Center for Infectious Diseases Centersfor DiseaseControl and Prevention Atlanta, G A 30333 Jane A. Lipscomb, Ph.D. Assistant Professor Department of Mental Health, Community, and Administrative Nursing School of Nursing Uni versity of California San Francisco, California 9414-3 Benjamin Y. H, Liu, Ph.D. Director, Environmental Division Mechanical Engineering Department Univarsity of Minnesota Minneapolis, Minnesota 55455

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W o rk sh o p P a rtic ip a n ts

P ro g r a m Committee continued

Patricia M. Simone M.D. Medical Epidemiologist Division of Tuberculosis Elimination National Center for Prevention Services Centers forDisease Control and Prevention Atlanta, G A 30333 D a w n G, Thair, M.S., C.I.H. Chief, Industrial Hygiene Section Hazard Evaluations and Technical Assistance Branch Division of Surveillance, Hazard Evaluations, and Field Studies National InstituteforOccupational Safety and Health Centers forDisease Control and Prevention Cincinnati, O H 45226

Laurence J . Doemeny, Ph.D. Coordinator Deputy Director Division of Physical Scicnces and Engineering National Institute forOccupational Safety and Health CentersforDisease Control and Prevention Cincinnati, O H 45226 RosaJyndJ. Kendall Coordinator Administrative Officer Division of Physical Sciences and Engineering National Institute forOccupational Safety and Health Centers forDisease Control and Prevention Cincinnati, O H 45226

K E Y N O T E

S P E A K E R S

Theodore C. Eickhoff, M.D. Arthur E Wheeler, P E Professor of Medicine President Division of Infectious Disease Wheeler Engineering Company University of Colorado - Health Srie&ce Towson M D 21204 Center Denver, C O 80262

W o rk sh o p P a rtic ip a n ts
W O R K S H O P P A N E L A E R O S O L

C H A R A C T E R I Z A T I O N

Benjamin Y. H. Liu, Ph.D.

Panel Chair
Director Environmental Division Mechanical Engineering Department University of Minnesota Minneapolis, Minnesota 55455 Frank J. Heart, M.S.Ch,H.tP.E.

Barry S. Fields, Ph.D. National Center for Infectious Diseases Centers fixDisease Control and Prevention Atlanta, G A 30333 David L Lnndgren, Ph.D. InhalationToxicology Research Institution Albuquerque, N M 87185 George Kubica, Ph.D. Consultant Dunwoody, G A 3033& Sergey Grin&hpun, Ph.D. University of Cincinnati Department of Environmental Health Cincinnati, O H 45267 Paul Baron, Ph D, Methods Research Branch Division of Physical Sciences and Engineering National Institute forOccupational Safety and Health Centers forDisease Control and Prevention Cincinnati, O H 45226

Panel Rapporteur
Branch Chief Environmental Investigations Branch Division of Respiratoiy Disease Studies National Institute forOccupational Safely and Health Centers for Disease Controland Prevention Morgantown, W V 26505 Eugene C. Cole, Dr.P.H.

Plenary Speaker
Senior Researcher Microbiologist Research Triangle Institute Center tor Environmental Analysis Research Triangle Park, N C 27709 Aino Neyalainen, Hi-D. Senior Research Officer Chief Department of Environmental Microbiology National Public Health Institute Kuopio, Finland

W o rk sh o p P a rtic ip a n ts

W O R K S H O P P A N E L S O U R C E CHARACTERIZATION A N D S O U R C E C O N T R O L

Jane A. Lipscomb, Ph.D.

Panel Chair
Assistant Professor Department of Mental Health, Community, and Administrative Nurs ing School of Nursing University of California San Francisco* California 94143 Paul A. Jensen, Ph.D.TPE, CIH

Jean McGrane, MS, Esq. Assistant Vice President Office of Occupational and Environmental Health Services N e w York City Health & Hospital Corp. N e w York, N Y 10036 Teresa A. Seitz, M.P.H., CIH Supervisory Industrial Hygienist Industrial Hygiene Section Hazard Evaluations and Technical Assistance Branch EH vision of Surveillance, Hazard Evaluations, and Reid Studies National Institute for Occupational Safety and Health Centers forDisease Control and Preverson Cincinnati, O H 45226 Michael L. Tapper, M.D, Hospital Epidemiologist Lenox Hill Hospital N e w York, N Y 10021 Frank S. Rhame, M.D. Hospital Epidemiologist University of Minnesota Hospital &. Clinic Minneapolis, M N 55455 Joan Sprinson, M P H , CIH Tuberculosis Control Branch California Department of Health Service* Berkeley, C A 94704 Theodore C. Eickhoff, M.D. Professor of Medicine Division of Infectious Disease University of Colorado - Health Science Center Denver, C O 80262

Panel Rapporteur
Industrial Hygienist Engineering Control Technology Branch Division of Physical Sciences and Engineering National Institute for Occupational Safety and Health Centers for Disease Control and Prevention Cincinnati, O H 45226 James M. Melius, M.D., Dr.P.H.

Plenary Speaker
Director Division of Occupational Health & Environmental Epidemiology N e w York State Department of Health Albany, N Y 12203-3399 Elizabeth A. Bolyard. RN, M P H Chief. Prevention Activity HIV Infections Branch Hospital Infections Program National Center for Infectious Diseases Centers for Disease Control and Prevention Atlanta, G A 30333 Wilbam K. Borwegen. M P H Director, Occupational Safety & Health Department Scrvice Employees International Union Washington, D C 20005

X X IV

W o r k s h o p Participants

W O R K S H O P P A N E L BUILDING DESIGNS

Douglas S. Erickson B.S.A.E.

Panel Chair
Director, Design and Construction American Hospital Association Chicago, JL 60611 Kenneth F. Martinez, M.S. EE.

Ronald E. Gover, B.S., AIA Vice President H K S Architects Dallas, T X 75201 Robert Greifinger, M.D. Deputy Commissioner/Chief Medical Of ficcr N e w York State D q x ofCorrectional Services Albany, N Y 12226 John E, McGowan, Jr., M.D. Director, Clinical Microbiology Grady Memorial Hospital Atlanta, Georgia 30335 Richard Rosen void, B.5., R A Chief, Officc of Plans & Construction Agency for Health Care Administration Tallahassee, F L 32308

Panel Rapporteur
Research Industrial Hygiene Engineer Industrial Hygiene Section Hazard Evaluations and Technical Assistance Branch Division of Surveillance, Hazard Evaluations, and Field Studies National Institute for Occupational Safety and Health Centers forDiseaseControl and Prevention Cincinnati, O H 45226 Georgeann Burrs, M.Arch.

Plenary Speaker
Principal Hie Austin Group White Plains N Y 10605 Leon Dunkley, B.S., A1A Group Director, Planning,Consultant Services N e w York City Health & Hospital Corporation N e w York. N Y 10013

XXV

W o rk sh o p P a rtic ip a n ts
W O R K S H O P P A N E L D E S I G N S V E N T I L A T I O N

Robert Hughes, M.S., P.E.

Panel Chair
Chief, Control Section 3 EngineeringControl Technology Branch Division of Physical Sciences and engineering National Institute for Occupational Safety and Health Centers for Di seaseControl and Prevention Cincinnati, O H 45226 Richard D. Hermans, B.M.E., P.E. Panel Rapporteur and

Paul Ninomura. M.E. Mechanical Engineer Office of Engineering Services US Public Health Service Seattle, W A 98121 Bud Pate Director of Licensing and Accreditation Kaiser Foundation Hospitals Pasadena, C A 91188 Mary Jane Phillips Mechanical Engineer Facilities Division Navy Bureau of Medicine & Surgery Washington, D C 20372 John A. Schaefer, MFS, CIH Environmental Health Officer The Johns Hopkins Institutions Office of Safety and Environmental Health Baltimore, M D 21205 Arthur F- Wheeler, P.E. President Wheeler Engineering Co. Towson, M D 21204 Richard L. Rjley, M.D. Professor Emeritus Departments of Environmental Health Science and of Medicine Johns Hopkins University Petersham, M A 01366

CO'Pltnary Speaker
General Manager. Facilities Operations and Maintenance St. Paul Public Schools St. Paul, M N 55108 Andrew J. Streifel Co-Plenary Speaker Environmental Health Specialist University of Minnesota. Environmental Health & Safety Boynton Health Service Minneapolis. M N 55455 612/626-5804 Lee Halhon Occupational Safety and Health Administration Salt Lake City. U T 84165 Walter J. Hicrholzer, Jr., M.D. Hospital Epidemiologist Yale - N e w Haven Hospital N e w Haven, C T 06504

xxvi

W O R K S H O P O P E N IN G AND C H A R G E T O P A R T IC IP A N T S

W O R K S H O P O P E N I N G R I C H A R D A. L E M E N , Ph.D. G o o d m o r n i n g a n d t h a n k y o u for c o m i n g to this scientific w o r k s h o p o n engineering controls in health care a n d related facilities. I bring y o u regards f r o m Dr. J. D o n a l d Millar, the Director o f N I O S H , w h o w a s called to W a s h i n g t o n t o d a y to testify before a Se na t e c o m m i t t e e about the extent o f occupational disease a n d injury in this country. A s a result h e ha s a s k e d that I deliver his r e m a r k s to y o u at this conference. I a m e*cited to see s u c h a diverse g r o u p o f scientists a n d health professionals gathered in o n e r o o m . Dr, Millar w a n t e d m e to especially m e n t i o n h o w pleased h e w a s to see Dr. T h e o d o r e Eickhoff, f r o m the University of C o l o r a d o Health Science Center, participating with us. Dr. Eickhoff a n d Dr, Millar trace their friendship b a c k to their E I S officer training d a y s w h e n Dr. E i c k h o f f w a s o n e o f his mentorsh a s b e e n a n inspiration to him. H e w a n t e d m e to m e n t i o n that Dr. E i c k h o f F s illustrious career in infectious disease

Oliver W e n d e l l H o l m e s * the 19th ccntury A m e r i c a n writer a n d physician o n c e wrote: I find the great thing in this w o r l d is not so m u c h w h e r e w e stand, as in w h a t direction w e are m o v ing: T o reach the port o f heaven, w e m u s t .some times sail with the w i n d a n d s o m e t i m e s against it, but w e m u s t sail, a n d not drift, n o r lie at anchor. Th is expresses exactly h o w I feel about t o d a y s conference. I a m very e n c o u r a g e d b y the direction in w h i c h w e are m o v i n g . O u r m e e t i n g h e re t oday clearly indicates that w e h a v e d e c i d e d to sail. W e will sail into the rising surge o f infectious disease in health care a n d related w o r k e r s b y c o m b i n i n g all o u r k n o w l e d g e into a collective p o o l o f information. Id o n t h a v e to tell y o u that airborne infectious diseases are a very real p r o b l e m a m o n g w o r k e r s in healthcare a n d related facilities.

W o rk sh o p O p e n in g and C h a rg e
Y o u are all a w a r e that infectious disease in the health care industry is m o r e than a p r o b l e m o n the horizon. It is an issue w h i c h d e m a n d s o u r i m m e d i a t e attention. W e h a v e clearly s ee n this in issues related to Hepatitis B a n d H T V transmission. A n d n o w drug-resistant tuberculosis is m a k i n g itself felt as a threat to w o r k e r s in hospitals a n d other health care settings. Controlling this p r o b l e m will require the best expertise o f infec tious disease controllers, industrial hygienists, a n d engineers. T h r e e varied disciplines, wi t h their different traditions a n d cul tures, will h a v e to unite for a c o m m o n goal. Th is m u s t b e successful in order to assure the protection o f w o r k e r s as well as patients. W e c a n expect that this conf l ue nc e will not b e without turbulence as these three disciplines g r o p e for a c o m m o n lan guage, c o m m o n understanding, a n d c o m m o n m e t h o d s of p r o ceeding. T o put it quite simply, w e will frequently b e sailing against the w i n d B u t w h a t really matters is that w e will be sailing not m e r e l y drifting or lying at anchor. T h e ship that will carry us is engineering controls. W e have

c h o s e n this vessel for m a n y reasons. It is engineering controls that are the ideal m e t h o d for controlling the transmission o f infectious disease a m o n g workers. If w e c a n c o u n t o n engineering controls to b e the m e t h o d o f prevention, th en w o r k e r s will not h a v e to rely o n personal protective e q u i p m e n t , w h i c h often h a s m a n y unreli able features. N o r will they h a v e to learn a n d follow tedious guidelines or prevention measures. It is crucial to r e m e m b e r that s o m c t h i n g very basic lies at the heart o f o ur e fforts here tod a y : the safety a n d health o f workers. preserve the lives o f workers. T h i s is w h y N I O S H dec id ed to c o n v e n e this w o r k s h o p . It is b o th o u r nature a n d o u r mi ss io n to

T w e n t y - t h r e e years ago. C o n g r e s s m a d e a national c o m m i t m e n t to the welfare o f the A m e r i c a n worker. O n D e c e m b e r 29, 1970, C o n g r e s s passed the Oc c u p a t i o n a l Safety a n d H e a l t h A c t o f 1970, p r o m i s i n g to provide safe a n d healthful w o r k i n g conditions for e very w o r k i n g m a n a n d w o m a n . It also created N I O S H a n d o u r

W o rk sh o p O p e n in g an d C h a rg e
sister ag en c y, O S H A .

OS H A

and N I O S H

are b o t h dedicated to the prevention o f

occupational diseases a n d injuries; h o w e v e r , w e arc different in m a n y w a y s . O S H A is in the D e p a r t m e n t of L a b o r a n d is primarily responsible for p r o m u l g a t i n g a n d enforcing occupational stan

dards to protect w o r k e r s f r o m the hazards of w o r k . T h u s , O S H A


d o e s risk m a n a g e m e n t . In contrast, N I O S H w a s created b y C o n g r e s s to b e a scientific institute a n d w a s p la c e d in a different department, the D e p a r t m e n t o f H e a l t h a n d H u m a n Services. T h e mis s io n o f N I O S H is distinct f r o m that of O S H A . C o n g r e s s c h a r g e d N I O S H to d o four things:

Research o n occupational diseases a n d injuries. Respond to requests for assistance b y investigating


p r o b l e m s o f health a n d safety in the w o r kp la c e.

Recommend standards to O S H A b a s e d o n scientific


findings.

Train professionals in this field.

A s N I O S H fulfills these responsibilities, w e are supported b y a vision, w h i c h guides o u r culture a n d research: D e live rin g on the

N a tio n s Prom ise: Safety and H ealth at Work f o r a ll People. . . through Prevention, *' T hi s vision propels us to fulfill o u r m a n d a t e
of protecting all the w o r k e r s in this country f r o m occupational disease, death, a n d injury. In short, N I O S H is the o n l y national health institute w it h the responsibility to exercise national scienlific leadership in protect ing the health o f workers. W e feel a sense o f obligation to w o r k e r s to assure that they are w o r k i n g in the safest possible conditions. T h i s m e e t i n g will help us carry out that role. It is m y a n d Dr. Millar s sincere w i s h that w h e n w e leave this w o r k s h o p , w e will return to o u r varied disciplines w i t h a real feeling o f a c c o m p l i s h m e n t . W e will h a v e a better idea o f the real

W o rk sh o p O p e n in g an d C h a rg e
nature a n d extent o f infections in w o r k e r s in health care a n d related facilities a n d o f h o w engineering controls c a n protect them. W e will h a v e d e v e l o p e d a national research a g e n d a that will close the g a p s a n d permit reliable r e c o m m e n d a t i o n s for protecting workers. In short, w e will b e sailing t o w a r d s a feasible solution. B u t p e r h a p s m o s t importantly, w e will realize h o w o u r collective k n o w l e d g e c a n prevent these w o r k e r s f r o m disease a n d death. Z h o r e s M e d v e d e v , the i m m i n e n t Soviet biologist, o n c e wrote: A s science progresses, the w o r l d w i d e cooperation of scientists a n d technologists b e c o m e s m o r e a n d m o r e of a special a n d distinct intellectual c o m m u n i t y o f friendship, in w h ic h , in place o f a n t a g o n ism, there is g r o w i n g u p a mu tually a d v a n t a g e o u s sharing of w o r k , a coordination o f efforts, a c o m m o n l a n g u a g e for the e x c h a n g e o f information, a n d a solidarity___ It is o u r h o p e that this precedent-setting m e e t i n g will create this k i n d o f solidarity b e t w e e n industrial hygiene, engineering, a n d infectious disease for the g o o d o f the workers. N o w I close b y t hanking several p e o p l e for the inspiration a n d perspiration they put into this meeting. First, M s . R o z Ke nd a l l o f N I O S H , w h o h a n d l e d the th o u s a n d a n d o n e logistical details. N ext, C o - C h a i r s Dr. M o r t o n L i p p m a n n o f N e w Y o r k University M e d i c a l C e n t e r a n d Philip B i e r b a u m o f N I O S H , w h o organ iz ed the m e e t i n g a n d w e r e instrumental in the selection o f the present ers a n d p r o g r a m content. A n d n o w I call o n Phil a n d M o r i to carry us forward.

W o rk sh o p O p e n in g an d C h a rg e
W O R K S H O P A G E N D A A N D C H A R G E P H I L I P J. B I E R B A U M T h a n k y o u v er y m u c h Dick; w e appreciate the ti me y o u t o o k to c o m e a n d b e w it h us at this important w o r k s h o p . I a m Phil B i e r b a u m and, as D i c k indicated, o n e o f the co-chairs o f the w o r k s h o p . T a m the director o f the N T O S H Division o f Physical S ci ences a n d E n g i n e e r i n g a n d I w e l c o m e y o u to m y h o m e here in Cincinnati a n d to the location o f o n e of the m a j o r facilities o f NIOSH. W h a t 1 a m g o i n g to d o this m o r n i n g , for a bout 1 0 minutes, is to take y o u t h r o u g h w h a t w e w a n t to d o for the next several days, the logistics o f w h a t w c w a n t to do, the agenda, the format, etc., a n d explain h o w w e h o p e the w o r k s h o p will evolve. T h e n I will introduce Dr. L i p p m a n n , m y co-chair, so that h e c a n present his v i e w s o n w h y w e are here a n d his vision a b o u t the w o r k s h o p . T h e first thing I w a n t to d o is to m a k e sure e v e r y b o d y has a n information packet a b o u t the w o r k s h o p . Y o u s h o u l d h a v e re ceived this pa ck e t w h e n y o u registered today. T h e packet includes the w o r k s h o p p r o g r a m , k e y n o t e a n d plenary papers, a list o f preregistrants, a n d information a b o u t Cincinnati. Also, at the b a c k o f that w o r k s h o p p r o g r a m * y o u will find a list o f o u r panel m e m b e r s w h o will h el p us during the w o r k s h o p , a n d also a list o f the P r o g r a m C o m m i t t e e , that Dr. L i p p m a n n a n d I co-chaired, w h o selected the speakers a n d d e v e l o p e d the w o r k s h o p p r o g r a m a n d format. So, I w o u l d appreciate it if y o u w o u l d l o o k thr ou g h the packet. B e f o r e I g o t h r o u g h the p r o g r a m a n d the format, I w a n t to r e - e m p h a s i z e w h a t Dr. L e m e n just said about w h y w e are here a n d the p u r p o s e o f the w o r k s h o p , w h i c h w a s stated in o u r preliminary w o r k s h o p a n n o u n c e m e n t s . T h e p u r p o s e of the w o r k s h o p (and if y o u bear w i t h m e I will r e ad it s o that I c a n e m p h a s i z e various points) is to:

W o rk sh o p O p e n in g a n d C h a rg e
* R e v i e w the nature a n d extent o f airborne transmis sion o f infections in w o r k e r s in health care a n d related facilities. * R e v i e w current data a n d n e w findings regarding the engineering control o f airborne infections that m a y h a v e relevance to occupational e x p o s u r e s in health care a n d other institutions. * * Identify k n o w l e d g e g a p s that m i g h t b e filled b y directed research. R e c o m m e n d a research a g e n d a (not just o n e for C D C a n d N I O S H , but a national research a g e n d a that all o f o u r constituencies a n d peers c a n use) that, if i m p l e m e n t e d , w o u l d close the g a p s a n d permit reliable r e c o m m e n d a t i o n s for protecting workers. O n e additional point I w o u l d like to m a k e in regard to a charge for the w o r k s h o p . W e n e e d to g o b e y o n d health care facilities with our recommendations. Correctional facilities, social service facilities a n d other related facilities also n e e d to b e considered. T h e r e is e v e n m o r e k n o w l e d g e n e e d e d about w h a t to d o for engineering controls in these other facilities as c o m p a r e d to health care facilities I n o w w o u l d like to g o t h r o u g h the p r o g r a m wi th you. This m o r n i n g w e h a v e t w o k e y n o t e speakers: o n e discussing a pe r s p e c tive o n airborne infections a n d the s e c o n d o n engineering controls ( e m p h a s i z i n g ventilation). T h is d o e s not m e a n that the papers are all e n c o m p a s s i n g or that y o u all will agree wi th w h a t is said, but the speakers will present their perspectives o n the t w o issues. T h e n , later this m or n i n g , after the break, w e will h a v e four plenary speakers w h o h a v e d e v e l o p e d w h a t w e will call discussion papers. T h e s e papers will b e u s e d b y o u r panel chairs a n d rapporteurs to lead o u r panels t h r o u g h their "w o r k i n g delibera tionsthat will start this afternoon a n d will e n d o n Friday m o r n ing. T h e four panels w e h a v e established are A e r o s o l Character ization S o u r c e Characterization a n d Control,** Building D e signs/' a n d Ventilation Designs. T h e plenary spe ak er will

W o rk sh o p O p e n in g an d C h a rg e
present their viewp oi n ts o n these four specific issues this m o r u ing. T h e r e will b e n o reaction to the papers at this point; they are b e i n g shared in this plenary session s o that attendees hear all the papers at the s a m e time. T h e n this afternoon, the panels will b e g i n their deliberations. O u r goal d ur i n g the panel deliberations is to h a v e the plenary speakers g o t h r o u g h their pa pe r s again so that the panels c a n get startedin regard to reacting to the r e c o m m e n d a t i o n s o f the plenary speakers; this process will take place o v e r the n ex t d a y a n d a half, a n d the panel chairs a n d rapporteurs will lead the panels t h ro u g h the process w i th the ultimate goal of d e v e l o p i n g the research agenda. W e h a v e u s e d this fo rm a t in the past a n d it has b e e n successful; w e are a n x i o u s to see if it w o r k s in this forum. T h e r e p ro b a b l y will b e a n overlap across the four areas; if there is a n overlap, it will e v o l v e as w e g o th ro ug h the s u m m a r y presen tations o n Friday. Also, w e h a v e a session that is not listed in the p r o g r a m for just the panel f r o m eight to nine t o m o r r o w mo r ni ng . T h i s session is p l a n n e d to let the panels see w h a t ki nd o f overlap there m i g h t b e a n d to get s o m e feel for miss in g information in case w e n e e d to redirect panel chairs a n d rapporteurs. Ag ai n , o n Friday m o r n i n g , after w e h a v e g o n e th ro ug h this iterative process, the panel chair a n d rapporteurs for e a c h panel will s p e n d a half h o u r or s o s u m m a r i z i n g their p a n e l s specific r e c o m m e n d a t i o n s . T h e n , Dr. L i p p m a n n a n d I will e a c h provide a 1 0-15 m i n u t e synopsis o f w h e r e w e think w e are a n d a n overall w o r k s h o p s u m m a r y . Hopefully, in 3 or 4 m o n t h s after all of the material is put together, w e will publish a Proceedings. F o r the attendees that are not participating o n the panels, there will b e time set aside for y o u r c o m m e n t s a n d questions that c a n b e a d d e d to the panel deliberations. U s u a l l y this c o m m e n t a n d question period will b e at a certain point in e a c h o f the sessions. T h e chair a n d rapporteur o f e a c h of the panels will control this ti me period to m a k e sure that w e stay w it h the ti me w e h a v e allotted.

W o rk sh o p O p e n in g and C h a rg e
I think that s all I w a n t to c o v e r as far as the charge for the w o r k s h o p , a n d the logistics of h o w w e w a n t to proceed. A t this point, I w o u l d like to introduce Dr. M o r t o n L i p p m a n n , w h o is a friend o f m i n e f r o m the industrial h y g i e n e c o m m u n i t y . H e is currently the chair o f the N I O S H B o a r d o f Scientific Counselors, w h i c h provides N I O S H w i t h advice o n o u r research a g e n d a s a n d o u r scientific a p p r o a c h to o u r research. H e is a professor at the N e l s o n Institute o f E n v i r o n m e n t a l M e d i c i n e , N e w Y o r k U n i v e r sity M e d i c a l Center. I w o u l d n o w like to h a v e h i m share wi t h y o u w h a t his visions are a b o u t the w o r k s h o p .

W o rk sh o p O p e n in g and C h a rg e
W O R K S H O P C H A R G E M O R T O N U P P M A N N

It s a pleasure to w e l c o m e all o f y o u to this w o r k s h o p , w h i c h is the culmination o f m o r e than a y ea r o f planning. Its genesis w a s at a n informal m e e t i n g that I h a d w it h D o n Millar in M a y o f 1992, after his k e y n o t e presentation at the an n u a l A m e r i c a n Industrial H y giene C o n f e r e n c e a n d Exposition. Dr. Miliar s k e y n o t e address discussed the history o f infectious disease control a n d the o p p o r tunities that w e r e b e i n g m i s s e d b e c a u s e o f a separation into different professional fields that don't n o r m a l l y c o m m u n i c a t e e n o u g h w i t h e a c h other. I suggested to h i m that the N I O S H B o a r d o f Scientific C o u n s e l o r s w o u l d b e very interested in helping address s u c h needs, especially in the case o f the national n e e d to reduce the s p re a d of multi-drug resistant tuberculosis. W e a g r e e d that there w a s a particularly urgent n e e d to protect w o r k e r s 1 health in the health care industry, a n d that b y c o m b i n i n g the talents o f N I O S H in ventilation control o f airborne contaminants, a n d the general interest a n d expertise in other areas o f C D C in recognizing a n d controlling infectious disease, real contributions could b e m a d e . W i t h the enthusiastic support o f Dr. Millar, other m e m b e r s o f the B o ar d , a n d several p e op le o n Phil B i e r b a u m s staff, w e initiated a series o f P r o g r a m C o m m i t t e e meetings. Their product is this w o r k s h o p . W e m a d e a m a j o r effort to identify the speakers at a n early stage. W e could thereby c o m m i s s i o n the writing o f the b a c k g r o u n d plenary a n d k e y n o t e papers early e n o u g h for t h e m to b e received a n d distributed to all of the m e m b e r s o f the w o r k s h o p panels in a d v a n c e to h el p simulate the panelists' thoughts o n these topics. W e h o p e that the w o r k s h o p will p r o d u c e c o n s e n s u s v i e w s a n d r e c o m m e n d a t i o n s . I w a n t to t h a n k all the authors. T h e y h a v e d o n e their j ob s v er y well, a n d h a v e given us excellent discussion papers. T h i s is a n unus ua l w o r k s h o p in m a n y w a y s . W e c o m e from

various scientific disciplines a n d n e e d to learn h o w to c o m m u n i cate m o r e effectively w it h e a c h other. Part o f o u r p r o b l e m is that

10

W o rk sh o p O p e n in g an d C h a rg e
w e often d o n t k n o w the literature in e a c h othersfields. A s a result, w e c a n t m a k e as m u c h contribution to solving o u r o w n parts o f the puzzle as w e could if w e h a d a m o r e c o m p r e h e n s i v e under st an di ng of the larger issues. T hi s w o r k s h o p provides a n opportunity for us to get to k n o w e a c h other better a n d to interchange o u r ideas, thoughts, a n d k n o w l e d g e . W e expect the Pr oceedings o f this w o r k s h o p to p r o v e to b e a n extraordinarily valuable resource. T h e publication o f these P r o c ee d i n g s will m a k e available a reference b o o k containing the state-of-the-art papers a n d their bibliographies, as well as the panel session s u m m a r i e s a n d r e c o m m e n d a t i o n s . T h u s , this w o r k s h o p represents a starting point for this diverse g r o u p o f profes sionals to start to d e v e l o p c o m m o n actions for addressing urgent w o r k e r health needs. W e o n the P r o g r a m C o m m i t t e e still h a v e m o r e w o r k to d o in pulling together the written contributions already m a d e a n d the w o r k s h o p s u m m a r i e s into a publication that will b e useful to e a c h o f you. W e expect that the P r o c e ed in gs will b e distributed widely, a n d that it will h a v e a beneficial i m p a c t o n the national research a g e n d a in this area. Ibelieve that w e h a v e all c o m e here w i t h o p e n m i n d s , a n d are ready to learn a n d absorb w h a t o u r colleagues f r o m other disciplines h a v e to teach. Part o f the p r o b l e m w e face is that w c h a v e relied for too lo n g o n old ideas a n d assumptions. M a n y o f t h e m are difficult to justify w h e n they are challenged, b e c a u s e t h e y re b a s e d o n general c onccpts a n d beliefs rather than o n data. W h a t w e n e e d is m o r e relevant data to either c o n f i r m or refute these assumptions, so that w c c a n m o v e a h e a d a n d b e able to address the research a g e n d a in a m o r e productive w a y . A i r b o r n e infection in health care facilities has not b e e n adequately reco g ni ze d as a m a j o r p ro b l e m . O n e result is that appropriate control techn ol og y h a s not b e e n validated or refined. Part o f the p r o b l e m is chronic u n d e r f u n d i n g o f research. If a d v a n c e s b e y o n d

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W o rk sh o p O p e n in g an d C h a rg e
current k n o w l e d g e are to b e m a d e w e are g o i n g to n e e d to devo te significant resources for a research agenda. W e , as individuals, n e e d to s p e a k to o u r professional organizations a n d to the larger c o m m u n i t y a b o u t collective efforts to address the urgent national n e e d to control airborne infection. Clearly, the public is interested in the spread o f multi-drug resistant tuberculosis (TB), but if w e focus o nl y o n T B , w c w o u l d b e mi ss in g a larger opportunity. If, in addressing a n d correcting s o m e of the p r o b l e m s of transmission for T B , w e put in place s y s t e m s that will reduce all hospital acquired infections w e will not o n l y avert mortality a n d pain a n d suffering, but m a k e a real contribution to ameliorating o u r health care cost c o n t a i n m e n t crisis. W h e n p e op le s p e n d extra w e e k s in the hospital b e c a u s e o f acquired infections, there are substantial m o n e t a r y costs as well as professional e m b a r r a s s m e n t a n d patient pain a n d suffering. W e h a v e a s s e m b l e d a truly outstanding list o f speakers for today s m o r n i n g session a n d w e n o w n e e d to proceed.

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KEYNOTE ADDRESSES

13

PERSPECTIVES ON AIRBORNE INFECTION IN HEALTH CARE FACILITIES


P re p a r e d by: T h e o d o r e C . Eickboff, M . D . Professor o f M e d i c i n e Division o f Infectious Disease University o f C o l o r a d o Denver, Colorado

I N T R O D U C T I O N Th is presentation has four objectives: first, to place current beliefs about airborne n o s o c o m i a l infections into a n historical context; second, to r e v i e w the possible sources o f airborne infection in the health care setting; third, to r e v i e w the m i c r o o r g a n i s m s that h a v e b e e n transmitted b y the airborne route in hospitals; a n d finally, to evaluate the relative i m p o r t a n c e o f airborne transmission o f infection in the overall p r o b l e m o f n o s o c o m i a l infection.

HISTORICAL C O N T E X T A n y presentation entitled Perspectives o n m u s t a c k n o w l

e d g e the cyclic nature o f beliefs a b o u t the routes o f transmission of infectious diseases (Riley, 1980). In 4 0 0 B C . , Hippocrates believed that airs, waters a n d places influenced the health o f populations. In the s e c o n d century A D . , G a l e n noted that w h e n m a n y sicken a n d die at once, o n e sh ou l d consider the air that w e breathe. H i s observations w e r e un de rscored b y the occurrence o f d r e a d e d e p i d e m i c s s uc h as T h e B l a c k D e a t h in E u r o p e during the

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K eyn o te Theodore G E ic k h o ff, P ersp ectives on A irb o rn e In fe ctio n s


14th century. T w o h u n d r e d years later, Fracastorius n o t e d that infection c o u l d b e transmitted b y direct contact, b y indirect contact, or f r o m a distance, that is, t h r o u g h the air. F o r the next several h u n d r e d years, airborne infection w a s thought to b e a m a j o r route of transmission, a n d so the m i a s m i c theory o f infection g ai n e d credence, leading to n a m e s like malaria. After the microbial nature o f infectious diseases w a s r e c og ni ze d in the mid-nineteenth century, the role o f contact in infection transmission w a s clearly identified, a n d g ai n e d rapidly in a c c e p tance. B y 1910, Cha rl es C h a p i n c ould write in his treatise On the

Sources and Modes o f Infection (Chapin, 1910): Without deny


ing the possibility o f [airborne] infection, it m a y b e fairly affirmed that there is n o e v i d e n c e that it is a n appreciable factor in the m a i n t e n a n c e o f m o s t o f o u r c o m m o n contagious diseases. W e are warranted, then, in discarding it as a w o r k i n g hypothesis a n d de v o t i n g o u r chief attention to the prevention o f contact infec tion H e did w a v e r a bit in the case o f tuberculosis, h o w e v e r , a n d co nsidered that disease m o r e likely than a n y other to b e airborne. C h a p i n ' s v i e w s persisted for the next 3 5 years. In 1935, h o w e v e r , W i l l i a m Firth Wells, a n e n gineer at H a rvard, b e g a n to challeage this d o g m a ( L a n g m u i r , 1980) a n d b e g a n to a r g u e that certain diseases, s u c h as measles, w e r e spread through the air b y droplet nuclei.Ultraviolet lights w e re in t r o d u c e d in to a f e w sc h ool s to te st this hypothesis a n d w e r e m e t w it h at least initial success. As recently as 1946, h o w e v e r , a c o m m i t t e e o f the A m e r i c a n Public He al t h Association wrote, in its final report, that: Conclusive e v i d e n c e is not available at present that the airborne m o d e o f transmission o f infection is p r e d o m i n a n t for a n y particular dis ease" ( S u b c o m m i t t e e Report, 1947). T h e next twenty-five years, o f course, sharply c h a n g e d beliefs a b o u t airborne transmission o f infectious disease, a n d put e p i d e miological theory o n a m o r e scientific basis. A l e x a n d e r L a n g m u i r , in a thoughtful r e v i e w ( L a n g m u i r , 1980), identified four areas o f study that h a v e led to a m o r e substantive understanding of the role

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K eyn o te Theodore C . E ic k h o ff, Persp ectives on A irb o rn e In fe ctio n s


o f airborne infection. T h e s e included, first, a n understanding of the creation a n d b e h a v i o r o f aerosols o f micro-organisms; second, a n understanding o f the physi ol o gy a n d function o f the respiratory tract, particularly the respiratory host def en se m e c h a n i s m s ; third, the study o f e xperimental airborne infections in ani ma ls a n d m a n ; a n d lastly, increased understanding o f the e p i d e m i o l o g y of both naturally occurring a n d accidentally acquired infection. K n o w l e d g e a n d understanding of the role o f airborne infection in the health carc setting has generally paralleled understanding o f the role o f airborne infection m o r e generally. In fact, it is p r o b a b l y fair to state that studies o f n o s o c o m i a l infection transmission h a v e often b e e n pivotal in understanding the broad roie o f airborne infection. T h e classic studies o f R i c h a r d Riley in the Baltim or e V e te r a n s Administration Hospital (Riley, et al 1959, 1962), for e x a m p l e , w e r e critical to understanding the airborne transmission o f tuberculosis in a n y setting.

S o u r c e s o f A i r b o r n e I n f e c t i o n in H o s p i t a l s Possible sources o f airborne n o s o c o m i a l infection are s u m m a r i z e d in T a b l e 1, W i t h i n the hospital the m o s t important a n d m o s t

Table 1 Possible Sources of Airborne Nosocomial Infection*


Inside t h e hospital: Infective dusts, aerosols Infected or colonized patients, staff, visitors Ventilation or air condition ing systems O u t s i d e t h e hospital: Soil D u s t f r o m construction, renovation Decaying organic materials Water (e.g., cooling towers)

^Modified from Schaal, 1991.


o b v i o u s sources are h u m a n beings, either patients, personnel or visitors. T o b e a n efficient source o f airborne infection, a person n e e d s to b e a disseminator or spreader o f s o m e pathogenic organism. S u c h a disseminator m a y b e a p e r s o n w i ih s y m p t o m a t i c

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K eyn o te Theodore C . E ick h o flf, P ersp ectives cm A irb o rn e In fe ctio n s


disease, as has b e e n described in n o s o c o m i a l outbreaks o f

tuberculosis a n d smallpox; alternatively, a disseminator m a y b e w h o l l y a s y m p t o m a t i c , a k i n d o f microbiological P i g p e n to recall the n a m e o f the w e l l - k n o w n Pe an ut s character. S u c h a s y m p t o m a t i c carriers h a v e b e e n well described as sources o f airborne n o s o c o m i a l staphylococcal infections. Sites f r o m w h i c h airborne dissemination h a s o ccurred include the nares, ph ar y nx , anus, skin a n d skin scales. O t h e r possible sources o f airborne infection within the hospital include dusts or aerosols f r o m the floor or furniture, f r o m potted plants or flower vases, showers, sinks, nebulizers, hu m i d i f i e r s , o r aspirating de v ic es .

C o n t a m i n a t e d ventilation or air-conditioning s y s t e m s h a v e b e e n implicated in s o m e n o s o c o m i a l airborne outbreaks, via infective aerosols, dust, or e v e n colonized filters (Schaal, 1991). O u t s i d e the hospital, there are a n u m b e r of possible inanimate s ources as w e l l , T h e s e m u s t include soils, acting either as a natural habitat o f certain pathogens, or soil that h a s b e e n c o n t a m i n a t e d b y feccs. W a t e r supplies m a y b e c o n t a m i n a t e d b y potential p a t h o gens and hospital. the c o n t a m i n a n t s m a y then b e amplified in certain Legionnaire's D i s e a s e has b e e n spread bo th b y the settings s u c h as cooling towers, or in holding areas within the airborne route f r o m c o n t a m i n a t e d cooling t o w e r water, a n d b y the generation o f infective aerosols f r o m w a t e r supplies within the hospital. Infective dusts m a y b e generated f r o m building c o n struction or renovation activities within the hospital, or located in i m m e d i a t e l y adjacent areas. In general, airborne n o s o c o m i a l p a t h o g e n s derived f r o m the inanimate e n v i r o n m e n t h a v e b e e n less virulent than those derived f r o m a n i m a t e sources, a n d h a v e t e n d e d to o c c u r primarily in areas in w h i c h very highly susceptible hosts are located, e. g., o n c o l o g y units, o r g a n transplantation units, a n d the like. Fu rt h er mo re , the n u m b e r of p a t h o g e n s that c a n spread via the airborne route f r o m dusts, soils, or construction areas appears to b e limited to a f e w bacteria a n d fungi that c a n survive in a dr y e n v i r o n m e n t for e x t e n d e d periods o f time.

IS

Keynote Theodore C Eickhoff, Perspectives o n Airborne Infections E t i o l o g i e A g e n t s in A i r b o r n e N o s o c o m i a l I n f e c t i o n A substantial n u m b e r o f viruses, bacteria a n d fungi are cap ab le o f spread via the airborne route in hospitals. T h e p o ssib ility of airborne transmission a n d the documentation o f airborne trans m i s s i o n are quite different, h o w e v e r , a n d the p r o b l e m is c o m p l i cated b y the fact that m a n y , if not m o s t o f the p a t h o g e n s to b e discussed are capable o f spreading b y m o r e than o n e route. M a n y c o m m o n respiratory viraJ infections, for e x a m p l e , m a y b e spread b y large droplets, actually a f o r m o f indirect contact, a n d b y droplet nuclei carried in the air. T hi s discussion will b e focused, therefore, o n p a t h o g e n s for w h i c h there is g o o d ev i d e n c e o f at least s o m e transmission via the airborne route. Viruses believed to b e spread at least in part b y the airborne route in hospitals are s h o w n in T a b l e 2. T h e c o m m o n respiratory viruses, including rhinoviruses, influenza a n d parainfluenza vi ruses, respiratory syncytial virus, a n d adenoviruses are included in this category. T h e e v i d e n c e in support o f airborne rather than droplet spread o f m a n y o f these viruses is often incomplete. T h e r e is g o o d epidemiological cvidencc, h o w e v e r , for airborne trans mission o f respiratory syncytial virus a n d adenoviruses in pediat ric w a r d s (Chanock,etal., 1961; Ga rdner, etal., 1973;Hall, 1981). T h e strongest epidemiological e vi d e n c e o f airborne transmission o f influenza c o m e s not f r o m the hospital setting, but rather f r o m a w e l l - d o c u m e n t e d ou tbreak that o ccurred o n a c o m m e r c i a l aircraft (Moser, et al., 1979). T h e r e is also s o m e epidemiological e v i d e n c e in support o f s u c h transmission in hospital w a r d s ( H o f f m a n a n d D i x o n , 1977). A m o n g the c o m m o n viral e x a n t h e m s , the e v i d e n c e in support of airborne transmission is quite strong wi th respect to varicellazoster virus a n d m e a s l e s (Valenti, 1992; Ayliffe a n d L o w b u r y , 1982). Ru be ll a m a y also b e spread b y the airborne route, but the e v i d e n c e is not as compelling.

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K eyn o te Theodore C . E ic k h o ff, Persp ectives on A irb o rn e In fe ctio n s


S i n c e the eradication o f smallpox, a n y consideration o f n o s o c o m i a l airborne transmission of this disease is pr obably o f on ly a c a d e m i c interest. T h a t this h a s o c c u n e d , h o w e v e r , is established b e y o n d a n y doubt. In 1970, a m a j o r ou tb r e a k of s m a l l p o x o cc u r r e d in a small hospital in M e s c h c d e , W e s t G e r m a n y ;a single i n d e x patient infected 17 other persons, including b ot h patients a n d personnel. T w o additional cases oc c u r r e d in a s e c o n d generation, a total o f 19 cases, w i t h three deaths. U s i n g a s m o k e generator, the investiga tors s h o w e d that aerosols f r o m the i n d e x patient7s r o o m spread not o n l y out o f the w i n d o w , b u t also into the corridor, u p a stairwell a n d into patient r o o m s o n floors a b o v e (Wehrle, 1970). Ironically, the v e r y last case o f s m a l l p o x in the w o r l d w a s d u e to airborne transmission, a tragic laboratory accident that resulted not o nl y in the death o f the victim, a 4 0 - y e a r o l d medical p h o t o g r a p h e r in the

Table 2.
V i r u s e s i m p l i c a t e d in A i r b o r n e N o s o c o m i a l Infections R h in ov i r u s e s Influenza a n d parainfluenza viruses Respiratory syncytial virus Adenoviruses Measles Rubella Smallpox Varice 11a-zostcr virus Certain enteroviruses

M e d i c a l S c h o o l at the University o f B i r m i n g h a m , E n g l a n d , but also in the suicide o f the s m a l l p o x laboratory director (Centers for D i s e a s e Control, 1 9 7 8 ; H a w k e s , 1979). T h e r e arc theoretical c o n c e r n s to b e raised a b o u t possible sprea d o f viral h e m o r r h a g i c fevers s u c h as L a s s a fever or E b o l a v i m s disease transmission via the airborne route in the hospital setting, but ev i d e n c e in support o f this possibility is f r a g m e n t a r y (Ayliffe a n d L o w b u r y , 1982). T h e recent ou tbreak o f Hantavirus-associ ated A d u l t Respiratory Distress S y n d r o m e in the southwe st e rn part o f the U n i t e d States (Centers for Disease Control a n d P r e v e n tion, 1 9 9 3 ) also raises s u c h concerns, w h i c h thus far s e e m to h a v e b e e n entirely theoretical.

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K eyn o te Theodore C . E ic k h o ff, Persp e ctive s on A irb o rn e In fe ctio n s


T h e r e is s o m e e vi d e n c e that certain enteric viruses m a y b e transmitted t h r o u g h the air. Particularly intriguing w a s a n out b r e a k o f w h a t apparently w a s N o r w a l k - l i k e virus gastroenteritis that o cc urred in a 6 0 0 - b e d general hospital in Toronto, Ontario in N o v e m b e r , 1 9 8 5 ( Sa w y e r , et al., 1988). T h e o utbreak occurred o v e r a t h r e e - w e e k period, a n d i n volved 6 3 5 hospital personnel, o v er a quarter o f the staff. N o c o m m o n f o o d or w a t e r source w a s found, a n d the investigators c o n c l u d e d that spread o f the o r g a n i s m within the hospital w a s p ro b a b l y b y the airborne route. A l t h o u g h a theoretical possibility, there is n o e vi d e n c e to support transmission o f b l o o d - b o r n e viral p a t h o g e n s s u c h as Hepatitis B virus or H T V t h r o u g h generation of aerosols in b l o o d banks, patient care areas, operating r o o m s , or laboratories. M o v i n g u p f r o m viruses, there is o n e rickettsial agent that s h o u l d b e ment io n ed , that b e i n g C oxiella bum etti, the etiologic agent o f Q fever. T h i s o r g a n i s m h a s n e v e r b e e n transmitted in the hospital setting, to m y k n o w l e d g e , b u t it h a s c a u s e d airborne infection in m ed i c a l school research laboratories that u s e d parturient s h e e p to study perinatal physiology. In a 1 9 8 0 o utbreak at the University o f C o l o r a d o H ea l t h Sciences C e n t e r (Meiklejohn, 1981), m o s t o f the 1 37 cases o cc u r r e d in staff m e m b e r s w o r k i n g in laboratories or offices a l o n g the routes u s e d in transporting s h e e p to their destination. Bacteria that h a v e b e e n implicated in airborne transmission in health care facilities are s h o w n in T a b l e 3. E v i d e n c e in support o f airborne transmission of bacteria is generally easier to obtain than in the case o f viruses, s i mp l y b e c a u s e it is technically easier to recover bacteria using air s a m p l i n g techniques. Yet, it m u s t b e r e m e m b e r e d that the m e r e demon st ra ti o n of viable bacterial p a t h o g e n s in the air d o e s not establish that airborne transmission h a s occurred. Bacteria that m a y b e transmitted airborne directly f r o m in* fected p e r s o n s or healthy carriers include G r o u p A strepto cocci, S. aureus, the m e n i n g o c o c c u s , C

diphtheriae,

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K eyn ote Theodore C E ic k h o if, P ersp ectives on A irb o rn e In fe ctio n s

B ordetella pertussis, and, o f course, M ycobacterium tuberculo sis . Bacteria that m a y b e airborne f r o m dust particles or f r o m aerosols generated within the hospital include a gain S. aureus,
tubercle bacilli, other mycobacteria, nocardia species, p s e u d o m o n a d s , enteric bacteria, a n d Legionellae, C o n t a m i nated or colonized ventilation o r air-conditioning s y s t e m s h a v e resulted in airborne spread o f Legionellae, p s e u d o m o n a d s ,

Clostridia* N ocardia , a n d p r o b a b l y Chlam ydia p s itta c i (Schaai,


1991). A m o n g the bacteria spread directly f r o m infected persons, patients or personnel, or f r o m a s y m p t o m a t i c carriers, S. aureus a n d tubercle bacilli are b y far the m o s t important. Airborne staphylococcal infection in hospitals h a v e b e e n particularly important in t w o settings: nurseries a n d operating theaters. K e y e x p e ri m en ts d o c u m e n t i n g airborne spread o f staphylococci in

Table 3. Bacteria that Cause Airborne Nosocomial Infection* From patients, staff, visitors:
G r o u p A streptococcus

Staphylococcus aureus Neisseria m eningitidis Bordetella pertussis M ycobacterium tuberculosis


F r o m infective aerosols: Pseudomonads

Acinetobacter Legionellae
O t h e r non-fermenters

From ventilation / air-conditioning systems:


Legionellae C lostridia N o rcardia * M o d i f i e d f r o m Schaai, 1991.

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K eyn o te Theodore C . E ic k h o ff, P ersp ectives on A irb o rn e In fectio n s


nurseries w e r e carried out b y M o r t i m e r a n d his colleagues in the early 1 9 6 0 s ( M o r t i m e r , 1966). In recent decades, h o w e v e r , staphylococcal cross-infection in nurseries appears to h a v e b e c o m e less prominentIn contrast staphylococcal post-operative w o u n d infections re m a i n a m a j o r pr o b l e m , particularly in proce du re s involving the insertion of prosthetic devices, including joints a n d valves. T h e r e r e m a i n s a great deal of controversy, h o w e v e r , as to the relative contribution to the p r o b l e m m a d e b y airborne transmission of staphylococci, as c o m p a r e d to transmission b y direct or indirect contact. F o r e x a m p l e , w h e n total hip arthroplasty w a s first U s i n g ultra-clean vertical introduced, post-operative infections, m o s t l y d u e to staphylo cocci w e r e unacceptably frequent. l ami na r airflow plus exhaust-ventilated clothing in the operating r o o m C h a m l e y a n d his c o - w o r k e r s w e r e able to s h o w a striking reduction in post-operative sepsis rates f r o m 9 % d o w n to 1 % ( C h a m l e y andEftekhar, 1969). Critics, h o w e v e r , pointed o u t that there w e r e n o concurrent controls in those studies, a n d that several other c h a n g e s w e r e introduced during the study period. S u r g e o n s i m p r o v e d their skills as they g a i ne d m o r e experience, operative techniques w e r e c h a n g e d , a n d operation duration decreased (Ayliffe a n d L o w b u r y , 1982). Furthermore, in s o m e other centers w h e r e ultra-clean air w a s not u s e d for total hip arthroplasties, infection rates w e r e c o m p a r a b l y l o w (Fitzgerald, 1980). T h e role o f airborne bacteria in operating r o o m s as m a j o r determi nants o f post-operative w o u n d infection rates in other kinds of surgical procedures r e m a i n s controversial as well. S o m e sur g e o n s in the U n i t e d States, notably D e r y l Hart, at D u k e U n i v e r sity, w e r e so c o n v i n c e d o f the significant role o f airborne trans m i s s i o n that th e y installed ultra-violet lights in their operating r o o m s (Hart, 1960). P ub li s he d data suggested that the use o f U V lights in those operating r o o m s w a s associated w i t h a v er y l o w rate, ap pr ox i m a t e l y 0 . 5 % o f infection in so-called refined clean w o u n d s , " a category o f surgical w o u n d s in w h i c h o n e w o u l d e xp e c t a n infection rate o f 1 . 0 % or less (Goldner, 1980).

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Keynote 'Theodore C E ic k h o ff, P ersp ectives ch i A irb o rn e In fe ctio n s

T h e National R e s e a r c h C o u n c i l in the 1 9 6 0 s s p o ns or ed a multi hospital controlled trial o f the role o f U V light in preventing post operative w o u n d infection (National R e s e a r c h Council, 1964). T h e results suggested that there w a s i nd e e d a reduction of the rate ofpost-operative infections i n 1 refined c lean w o u n d s f r o m 3 . 8 % to 2 . 9 % , but this category o f w o u n d s represented on ly 19 % o f all infections studied; thus this m o d e s t beneficial effect w a s lost in the over-all experience in the study, a n d w a s offset b y a n apparent detrimental effect of U V light in non-clean w o u n d s . Ultraviolet light w a s effective, h o w e v e r , in r educing the counts o f airborne bacteria in the operating r o o m s . C o n t r o v e r s y a bout the relationship o f quantitative bacterial coun ts in the operating r o o m a n d the risk o f subse qu e nt d e v e l o p m e n t of sepsis continues. Lidw el l a n d his colleagues in G r e a t Britain f o u n d a g o o d correlation b e t w e e n the level o f air c on tamination a n d s u b s e q u e n t sepsis rates in joint r e p l a c e m e n t procedures (Lidwell, et ah, 1983). Fitzgerald a n d colleagues at the M a y o Clinic w e r e not able to relate the level o f airborne bacteria to the risk o f w o u n d sepsis; they have, h o w e v e r , n o t e d that older operating r o o m s w i t h l o w e r rates o f air e x c h a n g e s e e m e d to h a v e higher post-operative infection rates than n e w e r ro om s , with higher rates o f air e x c h a n g e (Fitzgerald, et al, 1977). In 1993, the m o s t serious threat in airborne n o s o c o m i a l infection is that p o s e d b y M ycobacterium tuberculosis. T h e nature o f the threat is clear e n o u g h , a n d is highlighted b y a n u m b e r o f recent investigations o f hospital o u t b re ak s o f multi-drug resistant tuberculosis (Dooley, et al., 1992; Pearson, et al., 1992; Edlin, et al., 1992; B e c k - S a g u e , et al., 1992). All o f t h e m h a v e b e e n associated w i t h highly i m m u n o s u p p r e s s e d A I D S patients acting as index eases, a n d spread o ccurred within the hospital to other A I D S patients, patients highly i m m u n o s u p p r e s s e d for s o m e other reason, a n d to hospital staff. In o n e instance, a health care w o r k e r w it h H I V infection a n d tuberculosis w a s the i ndex case in a m a j o r outbreak in a city hospital (Zaza, et al., 1992). E v e n before the AIDS e p i d e m i c , there w a s already a b u n d a n t e v i d e n c e that

24

Keyn ote Theodore C . E ic k h o ff, P ersp ectives on A irb o rn e In fe ctio n s


tuberculosis c o u l d b e transmitted via the air in hospitals ( E h r e n k r a n z a n d Kicklighter, 1972). Tuberculosis isT in m a n y w a y s , the prototype airborne infection, since there is e vi d e n c e that tubercle bacilli are transmitted m o r e effectively b y the airborne route than b y a n y other. Dr o pl et nuclei, o w i n g to their v er y small size, m a y b e inhaled directly into the smallest subdivisions o f the l o w e r respiratory tract, the alveoli themselves. Steps necessary to control this threat will likely b e discussed extensively workshop. G r o u p A streptococcal airborne transmission in hospitals is fortu nately infrequent, but has occurred. T h e source has a l mo st invariably b e e n a physician or nurse, a n d spread h a s b e e n f r o m the nares, pharynx, vagina, or a n u s ( G o l d m a n n , 1992). M e n i n g o c o c cal n o s o c o m i a l infection has fortunately b e e n rare, but has p r o b ably occurred ( C o h e n , et al., 1979). In general, enteric gr a m- ne g a t i v e bacteria are spread only rarely, if at all, via the air, since they are quite susceptible to drying. O t h e r non-enteric g r a m - n e g a t i v e o r g a n i s m s , h o w e v e r , including at this

Pseudomonas a n d Acinetobacter , h a v e b e e n transmitted through


the air. Allen a n d G r e e n reported a n ou t b r e a k of multidrugresistant A cin e to b a cte r a n itra tu s infections in patients in neurosurgical w a r d s a n d the intensive care unit o f a general hospital (Allen a n d G re e n , 1987). M o s t o f the infections involved the respiratory tracts o f ventilated patients, but the respiratory e q u i p m e n t could not b e implicated as the source o f the outbreak. T h e investigators believed that airborne transmission p la y e d a m a j o r role in perpetuation o f this outbreak, b u t the proportion o f infection c au s e d b y airborne spread c o u l d not b e determined. It is w o r t h noting, h o w e v e r , that this particular o r g a n i s m has b e e n f o u n d to b e u ni q u e a m o n g g ra m- ne g a t i v e bacilli in its relative resistance to drying (Hirai, 1991). In the last t w o decades, Legionella pneum ophila a n d related species h a v e e m e r g e d as significant n o s o c o m i a l p a t h o g e n s that m a y b e spread via air. P r o b a b l y the lack o f e v i d e n c e of person-toperson spread facilitated accep ta n ce o f L e g i o n n a i r e s Di se as e as

25

K eyn o te Theodore C . E k k h o ff, P ersp ectives on A irb o rn e In fe ctio n s


a n airborne infection. S p r e a d t h r o u g h infectious aerosols h as P e r h a p s the m o s t

b e e n a m p l y demonstrated; several other e p i d e m i c s h a v e impli cated ventilation s y s t e m s (LaForce, 1992). vivid s u c h o ut b r e a k oc curred in M e m p h i s in the s u m m e r o f 1978; 4 4 cases o f L pneum ophila p n e u m o n i a o cc urred in patients in a particular w i n g o f a hospital ( D o n d e r o , et al., 1980). T h e investi gation revealed that the cooling t o w e r for a n auxiliary air-condi tioning s y s t e m w a s c o n t a m i n a t e d w it h the organism; n o r m a l aerosol drift occurred a n d w a s d r a w n into the air intake o f the hospital's ventilation system. T h i s ou tbreak e m p h a s i z e d again that careful consideration m u s t b e g i v e n to locating air intakes for ventilation systems. O t h e r bacteria implicated in spread thro ug h ventilation s y s t e m s h a v e i ncluded Clostridia, Nocardia, a n d p e r h a p s atypical m y c o bacteria. T h e r e h a v e b e e n several recent reports o f possible airborne transmission o f Nocardia, usually involving high-risk patients in special care units, s u c h as transplant recipients ( H o u a n g , etal , 1980; S a h a th e va n, et al., 1991). A m o n g the fungi (Table 4), only Aspergillus and, to a lesser extent, Z y g o m y e e s , h a v e b e e n implicated as m a j o r airborne hazards in the hospital setting. M o s t o f these outbreaks h a v e b e e n associated wi th hospital construction or renovation ( W e e m s , et al., 1987). A i r b o r n e aspergillus infections h a v e p r o v e n to b e a T a b l e 4.____________________________________________________________

Fungi that Cause Airborne Nosocomial Infection


A spergillus
Z y g o m y c e s ( M u c o r a n d others ) particular h a z a r d in special c ar e units in w h i c h severely granulocytopenic patients are housed. B o n e m a r r o w transplant patients are at particular risk, but the increased risk c a n b e controlled b y H E P A filtration a n d laminar airflow (Sherert 2 , et al., 1987; R h a m e , 1991).

26

Keynote -Theodore C E ic k h o ff, Persp ectives on A irb o rn e In fe ctio n s


T h e r e is a b u n d a n t e vidence that Pneumocystis c a rin ii m a y b e transmitted via air in anima l experiments. T h e r e is circumstantial e v i d e n c e that it has b e e n transmitted in nursery settings. T h e r e is n o direct evidence, h o w e v e r , that Pneumocystis c a rin ii is a significant n o s o c o m i a l pathogen, or that airborne transmission occurs in health care settings ( R h a m e , et al., 1984).

T H E R O L E O F A I R B O R N E S P R E A D IN N O S O C O M I A L INFECTION Finally, I w i s h to e x a m i n e the relative contribution o f airborne n o s o c o m i a l infection to the overall p r o b l e m o f hospital infection. A t the 1 9 7 0 International C o n f e r e n c e o n N o s o c o m i a l Infection, held at C D C , B r a c h m a n r e v i e w e d the topic a n d c o n c l u d e d that although airborne spread certainly a c c o u n t e d for s o m e n o s o c o m i a l infections, the exact size of the piece w a s u n k n o w n ( B r a c h m a n , 1971). H e estimated, b a s e d largely o n data available f r o m the then infant National N o s o c o m i a l Infections Study, that airborne spread a c c o u n t e d for 1 0 - 2 0 % of all endemic n o s o c o m i a l infections, accounting for a b o u t a o n e percent incidence o f infection a m o n g hospitalized patients. In a 1 9 8 0 r e v i e w o f airborne contagion, s p o n s o r e d b y the N e w Y o r k A c a d e m y o f Sciences, K u n d s i n concluded, b a s e d largely o n studies carried out at the Peter B e n t B r i g h a m hospital during the previous 2 0 years, that airborne spread in the operating theater a c c o u n t e d for 2 0 - 2 4 % of ail postoperative w o u n d infections ( K un ds in , 1980). O th e r s d o u b t e d that the proportion w a s that high, a n d w e r e skeptical of the i m p o r t a n c e o f absolute levels o f bacteria in operating r o o m air, although instances o f staphylococcal transmission f r o m a sur ge on to patients in the operating r o o m h a v e b e e n thor ou gh l y d o c u m e n t e d . T h e cooperative ultraviolet 1ight study, a) t h o u g h itdid not s h o w a dramatic effect of uItraviolet light in r ed u c i n g rates o f postoperative w o u n d infection, did not directly evaluate possible routes of transmission of bacteria causing postoperative w o u n d infection (National R e s e a r c h Council, 1964).

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K eyn ote Theodore C . E ic k h o ff, f^ rsp e ctiv e s on A irb o rn e In fe ctio n s


In a n extensive r e v i e w (Ayliffe, 1991), Ayliffe cited a n u n p u b lished study carried out in B i r m i n g h a m , E n g l a n d , in w h i c h the postoperative w o u n d infection rate in a n unventilated operating suite, during the y ea r p r e ce di ng installation of a ventilation system, w a s 8 . 8 % ; in the ye ar following installation of a p l e n u m ventilation s y s t e m wi th 2 0 air c h a n g e s per hour, the infection rate w a s 1 2 . 6 % ! F ur th e rm or e, there w a s a 5 0 % reduction in airborne bacterial counts after the ventilation s y s t e m w a s installed. H e cited e v i d e n c e that m o s t w o u n d infections are acquired in the operating r o o m f r o m the patient s o w n microbial flora, the bal a nc e b e i n g acquired m a i n l y f r o m staff present in the O R during surgery. Since air is an important source o f infection in infections involving insertion o f prostheses o f various kinds, the use o f ultraclean air a n d exhaust-ventilated clothing is frequently rec^ ommended. T h e value of this t e c h n o l o g y in other kinds o f surgical procedures, h o w e v e r , is doubtful. T h e p r i m a c y of p e o p l e as a source o f p r e s u m a b l y direct a n d indirect transmission as o p p o s e d to airborne transmission, o f n o s o c o m i a l p a t h o g e n s w a s supported b y M a k i , et al., w h o did extensive e n v i r o n m e n t a l microbiological s a m p l i n g of a n e w un i versity hospital in M a d i s o n , W i s c o n s i n before a n d after it w a s put inlo use ( Ma k i , et al., 1982). T h e attack rate o f n o s o c o m i a l infections in the n e w hospital w a s n o different f r o m the attack rate in iheold hospital, thus suggesting that o r g a n i s m s in the inanimate e n v i r o n m e n t contributed little if at all to e n d e m i c n o s o c o m i a l infections- In interpreting this study, h o w e v e r , w e m u s t recall that spread o f n o s o c o m i a l p a t h o g e n s f r o m p eo p l e via a n airborne route in the hospital setting is well established. It appears, h o w e v e r that B r a c h m a n w a s not far off in his 1 9 7 0 estimate ( B r a c h m a n , 1971), a n d a m o r e recent estimate o f the relative incidence o f airborne infections is a b o u t 1 0 % of the w h o l e o f e n d e m i c n o s o c o m i a l infection (Schaal, 1991). E p i d e m i c n o s o c o m i a l infections m u s t b e considered, as well. C D C studies carried out during the early 1 9 7 0 s suggested that

Keyn ote Theodore C . E ic k h o ff, P ersp ectives on A iib o m e In fe ctio n s


outbreaks o f n o s o c o m i a l infection in s e v e n hospitals participating in an intensive surveillance study represented o n l y about 2 % o f all patients w i t h n o s o c o m i a l infection (Haley, et al., 1985). W e n z e l a n d his colleagues estimated that outbreaks a c c o u n t e d for 3 . 7 % of n o s o c o m i a l infections in a large university tertiary care referral center ( W e n z e l , et al., 1983). A m o n g n o s o c o m i a l outbreaks Thus, investigated b y C D C f r o m 1 9 8 6 - 1 9 9 0 , o v e r 6 7 % w e r e related to products, procedures, or devices (Jarvis, et al.,1991). nent, at least o n a si mp l e statistical basis. A l t h o u g h reassuring, there h a v e b e e n s o m e disquieting trends in the last decade. Particularly w o r r i s o m e h a s b e e n the resurgence of airborne n o s o c o m i a l transmission o f tuberculosis, a p r o b l e m m a d e all the m o r e urgent b y the multidrug-resistant nature o f recent outbreaks. O u t b r e a k s o f airborne Legionellosis in hospi tals continue to occur, as d o airborne transmission o f Aspergillus causing b o t h e n d e m i c disease in certain special care units, and-of construction-related outbreaks. T hus, these co n c e r n s relate primarily to epidemic n o s o c o m i a l infections., unanticipated, a n d unpredictable in occurrence* T h e only predictable thing a b o u t e p i d e m i c n o s o c o m i a l infections is that they will continue to occur. O u r challenge is to m i n i m i z e this risk in hospitals, with ou t laying another m a j o r incremental cost o n o ur already precarious health care e c o n o m y . airborne outbreaks o f n o s o c o m i a l infection h a v e not b e e n p r o m i

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Acinetobacter anitratus: a n airborne m o d e o f spread? J


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W e e m s JJ, D a v i s BJ, T a b l a n O C , et al. Construction activity: a n i n d e p e n d e n t risk factor for invasive aspergillosis a n d z y g o m y c o s i s in patients w it h h e m a t o l o g i c mali gn a nc y. Infect Control. 1987; 8: 71-75. W e h r l e P F , P o s c h J, Richter K H , et al: A n airborne o u tbreak o f s m a l l p o x in a G e r m a n hospital a n d its significance with respect to other recent outbreaks in Euro pe . Bull W H O . 1970: 43: 6 6 9 - 7 9 . W e n z e l R P , et al. Hospital a cquired infections in intensive care unit patients: a n o v e r v i e w wi th e m p h a s i s o n epidemics. Infect Control. 1983; 4: 371. Z a z a S, B l u m b e r g H , B e c k - S a g u e C , et al. N o s o c o m i a l transmis sion of Mycobacterium tuberculosis infection a m o n g health care workers. Presented at the 3 2 n d annual Interscience C o n f e r e n c e o n Antimicrobial A g e n t s a n d C h e m o t h e r a p y . A m e r i c a n Society for Microbi ol o gy . O c t o b e r 1992, L o s A ngeles, C A .

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A PERSPECTIVE OF VENTILATION FOR HEALTH CARE AND RELATED FACILITES

P re p a r e d by: Ar t h u r E. Wh e e l e r , P E President W h e e l e r E n g i ne e ri ng C o m p a n y Towson, Maryland

I N T R O D U C T I O N P e r h a p s it all started m u c h earlier w h e n M r s . N e a n d e r t h a l scolded her m a t e T h e stench in this c a v e is m a k i n g us sick! Certainly w e c a n extract f r o m biblical reports dating b a c k 4 0 0 0 years e v i d e n c e o f an acute n e e d for ventilation N o a h s Ark. A s early as 1 5 0 0 B C , the ancient Egyptians identified silicate dust p r o d u c e d b y the cutting of construction stone as a c a u s e o f respiratory disease ( L o r d 1986). W i n d o w s for residences w e r e dec re ed b y Ch a rl es I o f E n g l a n d as a def en s e against p l a g u e a n d other diseases. H o w e v e r , the o u t d o o r air w a s often so foul as to b e unsuitable for ventilation. T h e air in L o n d o n w a s so b a d that the y ea r of 1 3 5 7 w a s designated T h e Y e a r o f the G r e a t Stink, E v e n in 1 6 61 L o n d o n s air w a s characterized as a n i m p u r e a n d thick mist, a c c o m p a n i e d w i t h a fulginous a n d filthy vapour, corrupting the lungs a n d disordering the entire habits ot the inhabitants1 b o d i e s /

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B e n Franklin w a s considered d e r a n g e d b y his a d v oc ac y, contrary to prevailing m e d i c a l opinion, o f o p e n i n g w i n d o w s at night in order to h a v e a constant s u p p l y o f fresh air in y o u r b e d c h a m b e r as a m e a n s o f preserving health(Franklin 1780). T h e nineteenth century w a s the occasion o f s o m e significant research a n d hypothecalion regarding the value o f ventilation. P e r h a p s the m o s t pertinent w a s that o f J. S. Billings, an A m e r i c a n physician, w h o in 1 8 9 3 e x p o u n d e d o n the co n n e c t i o n b e t w e e n ventilation a n d the prevalence of p u l m o n a r y tuberculosis, a n d r e c o m m e n d e d 6 0 c ubic feet p e r m i n u t e (cfm) o f o u t d o o r air per p e r s o n for continuously o c c u p i e d space, a n d that less than 3 0 c f m w a s inadequate. T h e A m e r i c a n Society o f H e a t i n g a n d Ventila tion E n g i n e e r s (an A m e r i c a n Society of Heating, Refrigeration, a n d A i r C o n d i t i o n i n g E n gi ne er s predecessor society) wi t h strong support f r o m hygicnists a n d physiologists, a d o p t e d the 3 0 c f m value as the m i n i m u m standard. T hi s necessitated m e c h a n i c a l ventilation. T h e rate w a s subsequently considered excessive a n d w e engineers w e r e held responsible for over de s ig n of ventilation s y s t e m s a n d w a s t i n g m o n e y (Klauss, et ah, 1970). S u b s eq u en t rvaluation of the health effects focused u p o n ventila tion air quality a n d consideration of b o d y o d o r as the controlling factor. This led to reductions in the r e c o m m e n d e d outdoor air ventilation rate a n d the substitutionary use of treated recirculated air. Currently, A S H R A E S t andard 62 - 1 9 8 9 , Ventilation f o r Accept

able A i r Q uality ( A S H R A E , 1 9 8 9 ) prescribes a m i n i m u m ou td o o r


ventilation rate of 15 cfim per pe rs o n w it h higher values for s o m e o c c u p a n c y classifications.

V E N T I L A T I O N O F H E A L T H FACILITIES T h e A S H R A E St an d a r d prescribes ventilation rates for hospitals a n d nursing a n d convalescent h o m e s b a s e d u p o n c f m o f ou td o o r air p e r p e r s o n for five space classifications a n d o n e (autopsy) b a s e d o n c f m p e r ft2 o f floor area. T h e sources for these values w e r e the G u idelines ( 1 9 8 3 /1 98 4) a n d the M i n i m u m R e q u i r e m e n t s

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K e y n o te A rth u r E . W h e e le r P E , A P e rsp e c tiv e o f V e n tila tio n


(1979) for Construction a n d E q u i p m e n t o f Hospital a n d M e d i c a l Facilities, Public He al t h Service ( P H S ) . T h e out do or air ventilation rates in these publications are presented in air c h a n g e s per h o u r (ach), C o n v e r s i o n to cfrn p e r p e r s o n for the A S H R A E St an d ar d w a s a c c o m p l i s h e d using the stated o c c u p a n c y p e r 1 0 0 0 ft7of floor s pace a n d a n unstated estimate o f nine feet ceiling height* T h e earlier P H S publication b e c a m e the source if the m o r e recent o n e prescribed n o o u t d o o r air rates. U n l i k e the federal guidelines the A S H R A E S t a n d a r d d o e s not prescribe total air c h a n g e rates. T h e P H S publications call for h ig h efficiency filtration o f the air supplied to spaces e m p l o y e d in patient treatment a n d care, thus recognizing the value o f particulate r e m o v a l a n d resulting r e d u c e d concentration o f particulates within the o c c u p i e d space to the health o f b o t h patients a n d staff. In 1 9 8 7 ( an d recently reaffirmed) the A m e r i c a n Institute o f Architects (A I A ) published guidelines w it h ventilation rates simi lar to the P H S Guidelines except for operating r o o m s . F o r these r o o m s b o t h o u t d o o r air a n d total air c h a n g e s w e r e r e d u c e d f r o m 4 a n d 2 0 a c h to 3 a n d 15 ach. T h e 19 91 A S H R A E Applications H a n d b o o k r e c o m m e n d s bo th o u t d o o r a n d total air c h a n g e rates for hospital spaces extracted f r o m the P H S M i n i m u m R e q u i r e m e n t s published in 1979. F o r operating r o o m s , these sources ad v oc at e 5 a n d 2 5 a c h for o u t d o o r a n d total air It is interesting to note that following W o r l d W a r II, eight a c h o f 1 0 0 % o u t d o o r air (no recirculation) w a s c o m m o n l y applied for operating r o o m ventilation. Th is w a s then increased to 12 a c h in 1 9 6 3 (Gaulin, 1963). In 1969, the o u t d o o r air c o m p o n e n t w a s r e d u c e d to 5 a c h b y the Public H e a l t h Service ( P H S , 1969). F o r operating r o o m s , there c a n b e perceived t w o c h a n g e s in yenti lation practice o v e r the last hal f o f the century. O n e ,reduc in g (he o u t d o o r air rate. Th is c a n b e attributed to several factors: i m p r o v e m e n t s a n d greater reliability o f filtration of recirculated air, i m p r o v e m e n t s in anesthesia, s c a v e n g e r ventilation, a n d the imperative for e n e r g y conservation. A n increase in total air circulation w a s fo ll o w e d b y a reduction, as represented b y the

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K e y n o te A rth u r E . W h e e le r P E , A P e rsp e c tiv e o f V e n tila tio n


A L A values. R e a s o n s for this are m o r e obscure, but m a y reflect recognition that airborne surgical infections are m o r e the c o n s e q u e n c e o f air contamination in the micro-environment o f the surgical procedure than the average concentration o f viable particulates within the operating r o o m . Total air c h a n g e has bearing o n the latter w h e r e a s r o o m air distribution has m o r e effect o n the former. Research Reports M a j o r e m p h a s i s o n study a n d research into ventilation of medical care facilities has centered chiefly o n the operating r o o m . A n u m b e r o f studies reported u p o n total a n d o u t d o o r air c h a n g e rates, r o o m air distribution techniques (both of s up p l y a n d return air), quality o f air filtration a n d anesthetics control. A study ( W o o d s , et al., 1 9 8 6 ) primarily directed t o w a r d e n e r g y a n d e c o n o m i c considerations r e c o m m e n d e d further investigation into control of the micro-envi ro n me nt . G a l s o n a n d G o d d a r d ( 19 6 8 ) p r o p o s e d ventilation rates for m o s t hospital spaces b a s e d o n pre-established criteria o f the m a x i m u m n u m b e r o f bacterial colonies per ft2 in the r o o m air. T h e rates proffered w e r e frequently higher than applied in c o m m o n practice b y H V A C s y s t e m designers. H o w e v e r , they w e r e b a s e d o n a rational, albeit stereotyped, analysis o f the protection of occupants. W i t h the exception of the risk to operating r o o m personnel f r o m anesthetic gases, the primary objective o f ventilation study a n d design for medical facilities is protection o f the patients, w h o are considered to b e m o r e vulnerable than the m e d i c a l a n d support staff. The a c k n o w l e d g e d risk of airborne infection b y M. tuberculosis to m ed ic a l - w o r k e r s has altered the picture (Riley, Nardell, 1993). A i r Filtration It is k n o w n that s o m e microbial diseases c a n b e transmitted t h r o u g h the i n d o o r air (National R e s e a r c h C o u n c i l 1987). Tuberculosis, influenza, staphylococcal infections, measles, m u m p s ,the c o m m o n cold a n d legionellosis are a m o n g those diseases identified (Stowlwijk, 1983). In addition, airborne fungi spores a n d fungi p r o d u c e d toxins are agents for hypersensitivity pneumonitis,

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K e y n o te A rth u r E . W h e e le r P E , A P e rsp e c tiv e o f V e n tila tio n


c o m m o n allergies a n d m o r e serious disease. T o x i n s p r o d u c e d b y several species o f fungus, such as aspergillus versicolor, are believed to b e carcinogenic to h u m a n s ( M o r e y , 1992), Droplet nuclei, containing pathogenic organisms, c a n b e carried a n d dispersed o n air currents. T h e typical size r a n g e h a s b e e n estimated at o n e to five m i c r o n s ( K u e h n , 1991), b u t extending b ot h a b o v e a n d b e l o w this range, w i t h the aver ag e size a b o u t three m i c r o n s (Riley, NardelJ, 1993). Particlesofthis size are respirable a n d c a n r e m a i n in suspension for days. S o m e require a large concentration to cause infection (Burge, 1990) w h e r e a s for T B a single m y c o b a c t e r i u m deposited in the lungs is sufficient. M i c r o o r g a n i s m s m a y also b e transmitted t h r o u g h the air o n host pa r ticles a n d e v e n as single o r g a n i s m s ( K u e h n , 1 9 9 1). T h e significance of the size o f these infectious particles is that they are respirable yet m o s t c a n b e r e m o v e d f r o m the air b y m e d i u m to high efficiency filters, thus reducing the probability of infection transmis sion. Typically fungi spores are similarly characterized in size b e t w e e n t w o a n d five microns. Their r e m o v a l c a n reduce allergic response. A standardized p e r f o r m a n c e test p r oc ed ur e for predicting particu late r e m o v a l efficiencies is still o n the w a y . H o w e v e r , such efficiencies h a v e b e e n published for e x t e n d e d surface air filters b y several sources (Ensor* et a1.s 1988), T h e r e is substantial agree m e n t that filters w i t h an A S H R A E dust spot efficiency o f 9 0 - 9 5 % ( A S H R A E S ta n d a r d 52.1-1992) will r e m o v e a pp ro x i m a t e l y 9 9 % o f particles in the o n e to five m i c r o n range. E v e n 6 0 - 6 5 % m e d i u m efficiency filter as c o u l d b e u se d in the H V A C s y s t e m serving administrative a n d other n o n - m e d i c a l s p a c e h a v e a r e m o v a l capability in the order o f 7 5 % . Bacterial r e m o v a l efficiencies h a v e b e e n d e t e r m i n e d (Luciano, 1 984) s h o w i n g e v e n m o r e effec tive pe rf or m an ce . H E P A filters, rated at 9 9 . 9 7 % efficiency for 0.3 m i c r o n particles, offer little i m p r o v e m e n t in effectiveness o v e r the 9 0 - 9 5 % dust spot for the p r e p o n d e r a n c e o f path og en i c a n d allergenic particles. T h e higher efficiency H E P A filters are m o r e costly a n d difficult to apply; consequently it is best to limit their use especially in H V A C s y s t e m to highly critical situations.

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K e y n o te A rth u r E . W h e e le r P E , A P e rsp e c tiv e o f V e n tila tio n


E v e n weli filtered recirculated air will contain n o x i o u s gases a n d vapors. T h e o u t d o o r air ventilation c o m p o n e n t is necessary to dilute s u c h c o n t a m i n a n t s unless g a s adsorbers or oxidizers are e mp lo ye d. T h e outd oo r air is not regarded as de vo i d of micro or ga n isms a n d should b e filtered along with recirculated air (Bernard, Cole, Claywell 1961). Providing substantial total air c h a n g e s utilizing well-filtered supply air is, as G a l s o d a n d G o d d a r d (1968) proposed, a n important factor in safeguarding b o t h patients a n d staff. Infection R i s k He al t h risks c a n b e incurred f r o m airborne pollutants generated within the inhabited areas o f the facility b y the occupants, p ro cesses or building materials. Pollutants m a y b e introduced with the o u t d o o r air t h r o u g h e nt r ainment o f effluent. T h e y c a n also b e p r o d u c e d within the ventilation s y s t e m s t h e m s e l v e s through the accum ul at io ns o f biological material a n d organic nutrient. T o x i c c he mi ca ls are occasionally unwittingly introduced as a biocide. Ventilation is countercffective if it introduces contaminants. Dilution o f c o n t a m i n a n t s generated within the spaces is s e c o n d a r y to source control as a health safeguard* A cc o rd in gl y, ventilation is primari ly intended to limit the concentration of those c o n t a m i nants that c a n n o t otherwise b e controlled. T h e A S H R A E ventilation standard includes a n analysis p r oc e dure for predicting the concentration o f s pace co n ta mi na nt s or determining the a m o u n t o f air necessary to maintain concentration limits. H o w e v e r , its application in assessing health risk is sorely limited b y lack of necessary situational d a ta A t best such solutions arc stereotyped a n d realistic predictions o f results are g oing to b e few. E v e n so the technique can prove useful in c o m p a r i n g s y s t e m p e r f o r m a n c e capabilities, s u c h as the significance o f total venti lation rates in operating r o o m s a n d isolation r o o m s . Nardell, in a n extension o f earlier studies, evaluated the role o f dilution ventilation as a control for the spread o f tuberculosis demon st ra ti ng b o t h its effectiveness a n d limitations (Nardell et al.( 1991). If relevant situational param et er s are k n o w n the incidence o f cross infection is predictable.

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K e y n o te A rth u r E . W h e e le r P E , A P e rsp e c tiv e o f V e n tila tio n


Predictions are obtainable t h r o u g h the application of the W e l l s Riley equation to evaluate risk f r o m inhalation o f infectious droplet nuclei b a s e d o n steady state conditions, u n i f o r m distribution of droplet nuclei a n d dilution ventilation throughout the space. C=S(l-e -w t) T h e t e rm s o f this equation are: C: S: the n u m b e r o f n e w infections predicted the n u m b e r o f susceptible persons in the e x p o s e d e nv ir on m e n t , the n u m b e r of infect ors the n u m b e r o f q u a n t a of infection a d d e d to the air per unit o f time, q u a n t a per hour(qph). T h e v alue is derived f r o m data relative to a specific episode* It is then e m p l o y e d to predict the n u m b e r o f infections u n d e r altered circumstances, e.g., increased ventilation rate. T h e value is influenced b y a n u m b e r o f factors s u c h as the concentration o f airborne droplet nuclei a n d the virulence of the m i c r o o r g a n i s m g e n u s a n d species. T h e r a n g e in values for various situations involving tuberculo sis w a s reported b y Nardell to b e 1.25 to 2 5 0 q p h . In contrast, a m e a s l e s case in a school p r o d u c e d a n estimated 5 4 8 0 q p h . the respiration rate (air s a m p l e d ) per occupant,cfm.

I: 4

i; Q

e x p o s u r e time, hours. the ventilation rate in cfm. O n l y outdoor air w a s considered as the m e a n s of dilution in the cited study.

It is perceived that the usefulness o f this predictive technique extends b e y o n d application to tuberculosis to other airborne diseases a n d re sponse to allergenic o r g a n i s m s p r o d u c e d within the space. Application o f the equation circumscribes the limits o f effectiveness of reasonable ventilation rates in disease control. B e y o n d those limits, s o ur c e control, irradiation, protective safeguards or other alternatives arc g o i n g to b e required for protection o f e x p o s e d individuals.

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K e y n o te A rth u r E . W h e e le r P E , A P e rsp e ctiv e o f V e n tila tio n


T h e use o f the W e l l s -R il ey equation is e x t e n d e d a further step to e n ab l e p e r f o r m a n c e c o m p a r i s o n s o f alternative dilution ventila tion rates, air conditioning s y s t e m p e r f o r m a n c e a n d filter efficien cies. S i m p l y stated, a rate o f infection incidence ( C ^ is established for a b a s e ventilation rate p r o d u c e d b y a selected H V A C system. T h i s rate is e qual to the o u t d o o r air ( p r e s u m e d to b e free o f the infectious o rg a n i s m s ) plus the recirculated air, discounted to a c c o u n t for the inefficiency o f the filtration in r e m o v a l o f the infectious particle (droplet nuclei). A s e c o n d rate o f infection incidence (C) c a n b e calculated for an alternative condition a n d then divided b y the b a s e rate to establish a p e r f o r m a n c e or infection risk i n d e x (I = C / C ^ . T h i s technique is submitted for m o r e c o m p l e t e presentation at A S H R A E I A Q 9 3 C o n f e r e n c e this a u t u m n . A p r e v i e w o f the index application to a school c l a s s r o o m is s h o w n o n o n e o f the visuals. Several observations o f the c l a s sr oo m analysis c a n b e transposed to health care situations. If a risk reduction in the order o f 1 0 to 1 is desired, as m i g h t b e to protect m e d i c a l personnel f r o m T B infection, dilution ventilation alone is not a solution. If the virility or concentration o f the infectious agentis v er y high, source control (total isolation) o r e x p o s e d p er s o n protection are the only apparent solutions.

Health Risk Effects of HVAC Systems


Intake locations: It s e e m s axiomatic that intakes to air suppl y Y e t this h a s p r o v e d s y s t e m s sh ou l d b e located a w a y f r o m the discharge o f exhaust, c o m b u s t i o n stacks a n d cooling towers. deceptively difficult. Physical p l a c e m e n t of m e c h a n i c a l e q u i p m e n t r o o m s in a m a n n e r that c a n predictably avoid e n t r a i n m e n t o f n o x i o u s materials is a challenge. Better to design the points o f discharge o f effluent a w a y f r o m intakes. T h e m o r e flagrant violations o f the separation principle often o ccur w h e n s up p l y or exh au st s y s t e m s are a d d e d to existing buildings. Factory built air conditioning units: C o m m o n features o f s u c h e q u i p m e n t , especially pop ul ar o v e r the last t w o decades, that

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K e y n o te A rth u r E . W h e e le r P E , A P e rsp e c tiv e o f V e n tila tio n


increase the probability o f the H V A C s y s t e m b e c o m i n g a source o f contami n at io n are: * * * * * inaccessible access to c o m p o n e n t s . R a t cond en sa t e p a n s w i t h side drain connections. L o w efficiency filters. Mine ra l w o o l insulation e x p o s e d to the air stream. Inadequate provision for h u m i d i t y control.

Better e q u i p m e n t is n o w b e c o m i n g available as ma nufacturers react to in d o o r air quality c o n c e r n s o f their customers; but only t h r o u g h o w n e r a n d designer recognition o f its value will it be selected for o u r medical facilities. H u m i d i t y control: M a n y older systems maintain humidity b y recir culating water sprays. T h e s e are recognized amplifiers of bioaerosols a n d causes of heat transfer e q u i p m e n t depredation. M a i n t e n a n c e is so b u r d e n s o m e their use is usually terminated a n d wintertime humidification discontinued. Steam, free o f boiler treatment c h e m i cals a n d applied in a m a n n e r that will avoid wetting duct linings a n d d o w n s t r e a m filter, is the preferred m e t h o d of humidification. T e r m i n a l humidifiers are s o m e t i m e s installed in the individual s u p p l y air ducts fed b y a c o m m o n operating suite system. T h e range of design temperature a n d humidity conditions prescribed for operating r o o m s can b e m e t b y a single central humidifier control providing a moisture content o f approximately 6 0 grains per p o u n d o f dry air. F o r specific operational procedures the temperature range m a y b e stretched b e y o n d n o r m a l design parameters. E v e n then the resultant relative humidity hardly represents a health risk or comfort c o m p r o m i s e . Neglected m a i n te na nc e o f terminal humidifiers a n d their controls can, o n the other hand, h a v e serious consequences, w h i c h can b e c o m p o u n d e d if filters are placed d o w n s t r e a m of the humidifiers. W e t (or dirty a n d wet) filters will reduce supply airflow with the probability o f creating a negative pressure within the operating room. F o r m o r e reliable control a n d to avoid cross contamination b e t w e e n operating rooms, a n individual airconditioning s y s t e m for each is preferred, but this is frequently not feasible.

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K e y n o te A rth u r E . W h e e le r P E , A P e rsp e c tiv e o f V e n tila tio n


S p a c e pressurization: A positive or negative s p a c e pressure

relative to adjacent spaces is generally ac hieved b y a deliberate i m b a l a n c e o f supply a n d exha u st airflows. T h e actual pressure differential created is e x t r e m e l y small a n d virtually unpredictable du ri n g design unless the r o o m is o f special sealed construction (ASHRAE 1991). Pressure relationships c a n b e c o m p l e t e l y Such upset, e v e n reversed, b y d o o r a n d w i n d o w openings.

relationships c a n also b e c o m p r o m i s e d s im p l y b y depredations o v e r t i m e o f the adjustments o f airflow regulating devices t h r o u g h out the s y s t e m serving the critical ro om s . O v e r reliance u p o n the protection p r o v i d e d b y i m b a l a n c e o f airflows incurs a risk. A n t e r o o m s w i t h i n d e p en de n t air supply and/or ex ha us t as well as sealing o f all o p e n i n g s are p r o v e n techniques. In existing hospi* tals* the n e e d arises to convert ordinary patient r o o m s into isola tion r o o m s (positive or negative). W h a t then?

Variable Air Volume (VAV) Systems


V A V s y s t e m s are o n e o f the m o s t popular co ncepts o f air c o n d i tioning. R o o m temperature control is a c c o m p l i s h e d b y regulating the supply airflow. Its use has b e e n e x tended to patient care space, w h e r e f ormerly constant supply airflow with the r oo m ' s t e m p e r a ture controlled b y c h a n g i n g the supply air temperature h a d b e e n c ons id er ed essential. A c c e p t i n g the e ne r g y use a n d cost benefits of V A V , usually involves c o m p r o m i s e w it h i nd o o r air quality objectives. M o s t V A V s y s t e m s operating t o d a y are controlled in a m a n n e r that rc du ce s o u t d o o r airflow in proportion to the r e d u c tion in total s y s t e m supply airflow. M o r e o v e r , if exh a us t airflow is constant, a shift f r o m positive to negative pressure m a y o c cu r in individual spaces or the entire building caus in g infiltration of potentially c o n t a m i n a t e d air.

Considerations for the Future


Shifting populations will continue to create a n e e d for n e w medical facilities. H o w e v e r , with the pressure to contain medical costs, there is likely to b e increased e m p h a s i s o n the m o r e effective use of those n o w existing. M a n y o f today s air conditioning s y s t e m s are old, less able to p e r f o r m as they o n c e could. A t their best they w o u l d hardly

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K e y n o te A rth u r E . W h e e le r P E , A P e rsp e c tiv e o f V e n tila tio n


m e e t current indoor air quality a n d m e d i c a l treatment criteria. U p g r a d i n g or r e p l a c e me nt m u s t occur. R e p l a c e m e n t co ncepts for desired i m p r o v e m e n t are not a l w a y s e as y or obvious. R e d u c t i o n s in health risk to building o c c u p a n t s f r o m airborne infection are likely to involve i m p r o v e d source control t hr o u g h isolation a n d containment, elimination o f k n o w n reservoir a n d amplifiers o f m ic r oo r g a n i s m s , a n d better ventilation techniques. W e a k n e s s in the ho u se ke e p i n g , m a i n t e n a n c e a n d operation of H V A C e q u i p m e n t is areality, but m a n y past design a n d construc tion practices h a v e m a d e these functions h ar d to accomplish. I m p r o v e d design for better c o m p o n e n t access has b e e n m e n tioned. U p g r a d i n g filters for higher efficiency c a n often b e a c c o m p l i s h e d thr ou gh n e w filter ceil designs at favorable cost a n d r e d u c e d maintenance. Dirt collecting r o o m units c a n b e replaced with m o r e cleanable designs ( n o w c o m i n g o n the m ar k e t ) or, better yet, w i t h all air systems. Ultra l o w te mperature all-air s y s t e m s take less s p a c e a n d m a y e v e n cost-justify r e p l a c em en t t h r o u g h operational savings. Isolation o f infected patients m a y b e facilitated b y application of di sp l ac em en t ventilation principles c o u p l e d w i t h local e x h a u s t ne ar the patient s h e a d as a m e a n s of source control. T h e u s e o f air curtains at patient r o o m d o o r w a y s offers the opportunity for i m p r o v e d isolation w h e r e a n t e r o o m s are impracticable. T h e e x p a n d e d u s e o f h i g h total air c h a n g e rate r o o m ventilating sys te m s n o w b e i n g e m p l o y e d for protection o f i m m u n o - s u p p r e s s e d or - c o m p r o m i s e d patients a n d ultra violet irradiation or both, m a y also b e applied to protect staff a n d visitors. T w i n d u c t air s y s t e m c oncepts c o m b i n i n g the desirable features o f V A V a n d constant v o l u m e air conditioning c a n a u g m e n t or replace existing V A V s y s t e m s to u p g r a d e i nd o o r air quality a n d c o m f o r t control. It is h o p e d that this limited list o f suggestions m a y stimulate the discussions o f the w o r k s h o p s t o w a r d the a c h i e v e m e n t o f the goals of the conference.

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R E F E R E N C E S A S H R A E . S t a n d a r d 6 2- 1 9 8 9 , Ventilation for A c c e p t a b l e Air Quality. Atlanta: A m e r i c a n Society o f Heating, Refriger ating, a n d A i r Co nd it i on in g Engineers, Inc., 1 9 8 9 A S H R A E . C h a p t e r 7, H e a l t h facilities c o m f o r t air conditioning, H V A C Applications. A S H R A E H a n d b o o k , 1991. B e r n a r d H R , C o l e W R , C l a y w e l l JC. Recirculation o f air in the surgical suite. Hospitals, Journal o f the A m e r i c a n H o s p i tal Association. N o v e m b e r 1, 1961. B ur g e , H . Bioaerosols: prevalence a n d health effects in the indoor en vi ro nm en t . Journal o f Al le rg y a n d Clinical I m m u n o l ogy, N o v e m b e r , 1990. E n s o r D S , V i n e r A S , H a n l e y JT, L a w l e s s P A , R a m a n athan K , O w e n M K , Y a m a m o t o T, S pa r k s L E . A i r cleaner tech nologies for indoor air pollution. A S H R A E I A Q 8 8 , E n g i neering Solutions to I n d o o r A i r P ro bl em s, 1988. Franklin B T h e art of procuring pleasant d r e a m s . P o o r R i c h a r d s A l m a n a c , circa 1780. G a l s o n E, G o d d a r d K R . Hospital air conditioning a n d sepsis control. A S H R A E Journal, July, 1968. G a u l i n R P . H o w to k e e p infection out o f the air. M o d e m Hospital. M a r c h , 1963. K l a u s s A K S Tull R H , R o o t s L M , Pfafflin JR. History o f the c h a n g i n g co ncepts in ventilation requirements, A S H R A E Journal, June, 1976. K u e h n T H . M a t c h i n g filtration to health requirements. A S H R A E Transactions Vol. 97, Pl.2, 1991. L o r d D . A i r quality in w e s t e r n culture: a short history. A S H R A E , I A Q 8 6 , M a n a g i n g In d o o r A i r for He al t h a n d E n e r g y Conservation, 1986. L u c i a n o JR. N e w c oncepts in F r e n c h hospital operating r o o m H V A C systems. A S H R A E Journal, February, 1984. M o r e y P R . Microbiological c o n t a m i n a n t s in buildings: p r e c a u tions du r i n g remediation activities. A S H R A E , I A Q 9 2 , E n v i r o n m e n t s for People, 1992.

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Keynote Arthur E. Wheeler PE, A Perspective of Ventilation


Nardell EA, Keegar J, Cheney SA, Etkind SA. Airborne infection: theoretical limits of protection achievable by building venti lation. American Review of Respiratory Disease, 1991. National Research Council, Committee on Indoor Air Quality. Policies and procedures for control of indoor air quality. National Academy Press, 1987. Public Health Service. General standards of construction and equipment for hospital and medical facilities. PHS Publi cation 930-A-7,1969. Riley RL, Nardell EA. Controlling transmission of tuberculosis in health care facilities. 1993 Plant Technology and Safety Management Series/No. 1, 1993. Stowlwijk J. Health effects of indoor contaminants. ASHRAE Transactions, Vol. 89, Pt.l, 1983. Woods JEt Braymen DT, Rasmussen RW, Reynolds GL, Montag GM. Ventilation requirement in hospital operating rooms, parts 1& II control of airborne particles. ASHRAE Trans actions, Vol. 92, Ft. 2, 1986.

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PLENARY ADDRESSES

49

AEROSOL CHARACTERIZATION

Prepared by: Eugene C. Cole, Dr.P.H. Senior Research Microbiologist Center for Environmental Analysis Research Triangle Institute Research Triangle Park, North Carolina

INTRODUCTION
The setting of a national research agenda to investigate, evaluate, and recommend strategies for engineering controls for the preven tion of airborne infectious disease transmission to health care and related workers requires consideration of the factors relevant to aerosol characterization. Those factors include aerosol genera tion, particle sizes and concentrations, organism viability, infectivity and virulence, airflow and climate* and environmental sampling and analysis. The major focus of such planned research stems from the increasing incidence of tuberculosis, particularly the multiple drug resistant (MDR) variety in the general hospital population, the severely immunocompromised, and those in atrisk and confined environments such as prisons, nursing homes, and shelters for the homeless. Many workers are in close contact with individuals having active, undiagnosed, or insufficiently treated tuberculosis. Additionally, such workers are similarly exposed to a variety of pathogenic human viruses, and upon occasion, to other highly infectious disease agents. This report thus focuses on aerosol characterization in an attempt to identify those research needs that can be systematically addressed, and

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Aerosol Characterization Eugene C Cole, Dr.P.H.


result in proven, applied engineering approaches to the protection of workers routinely or periodically exposed to airborne infec tious disease agents.

BACKGROUND
In 1991 there were more than 26,000 active tuberculosis (TB) cases in the United Slates a 2.3% increase over 1990and 18.4% over 1985 (Lewis, 1992), This dramatic increase was primarily among the homeless, drug abusers, and those infected with the human immunodeficiency virus (HIV). The immigration of individuals from areas of high incidence is another causative factor (MMWR, 1990). Additionally, individuals who have failed lo complete their TB treatment have fostered the develop ment of multiple drug resistant strains of the primary causative agent, Mycobacterium tuberculosis* According to the CDC, virtually all new infection in the country today is contracted through the aerosol route from infected patients who arc coughing and dispersing infective droplet nuclei into the air (Snider, 1992). Health care and other workers exposed to confined and TBprevalent populations are very much at risk of infection. In an intensive care unit, 14 of 45 (31%) hospital staff who were exposed to an active, undiagnosed TB case over a five day period, were infected (Catan2aro, 1982), and a prison guard on immuno suppressive therapy contracted a fulminant and fatal case of tuberculosis from HTV infected inmates (MMWR, July 1992). Tuberculosis has been declared an endemic and nosocomial infection in nursing homes (Schlossberg, 1988). Tuberculosis is a severe, infectious disease, predominantly pul monary, that is caused by Af. tuberculosis and M . africanum primarily from humans, and M . bovis primarily from cattle (Benenson, 1990). Those infected with HTV are also predisposed lo infection with other mycobacteria to include Af. aviumt Af. intracelluiareyand Af. scrofulaceum (Blaseret aL, 1986). Tuber culosis occurs when airborne droplet nuclei containing few or even single infectious units may bypass the bronchial mucociliary

52

Aerosol Characterization Eugene C. Cole, Dr.P.H.


apparatus and reach and multiply in the terminal air spaces (Des Prez and Heim, 1992). Infection in the lungs commonly begins in the lower division of the lower lobe, the middle lobe, the lingula, and the anterior portion of the upper lobes; and while in most cases there is a single initial focus, one-fourth or more of cases show multiple foci (Des Prez and Heim, 1992). Bacilli are ingested by alveolar macrophages, continue to multiply, and spread to re gional lymph nodes where progressive disease may occur rapidly or after many years. In children and the elderly, the primary focus may become an area of advancing pneumonia (Des Prez and Heim, 1992). In addition to tuberculosis, health care and related workers remain at risk for contracting other infectious airborne diseases in the indoor environment to include those that are. viral (influenza, measles, chickenpox), chlamydial (psittacosis), bacterial (Legionnaires disease), and fungal (aspergillosis).

OBJECTIVE
The objective of this paper is to review the current status of infectious aerosol characterization and to identify and prioritize those research needs relative to the application of engineering controls for the prevention of airborne infections in workers in health care and other related facilities. The infectious aerosols of consideration are those that are generated as respirable size particles by both human and environmental sources, and have the capability of remaining viable and airborne for extended periods of time in the indoor environment. This definition precludes those skin and mucus membrane exposures occurring from splashes (rather than true aerosols) of blood or body fluids containing infectious disease agents. AEROSOL CHARACTERIZATION An assessmentof aiibome infectious entities requires investigation into their generation, as well as their particle sizes, aerodynamic

53

Aerosol Characterization Eugene C. Cole, Dr.P.H.


properties* concentrations, infectivity and virulence, and viability in relation to climate factors (temperature, relative humidity). B io aero so l G eneration Human Source Most respiratory infections (mycobacterial, viral) are transmitted by the airborne route from human sources and are due to the inhalation of droplet nuclei. Such droplet nuclei are small (<6^m) infectious particles of respiratory secretions that are aerosolized by coughing, sneezing, talking, or singing. A cough can generate some 3,000 droplet nuclei, as can talking for five minutes (Des Prez and Heim, 1992). A sneeze can generate as many as 40,000 droplets, which can evaporate to particles in the 0.5-12 |im range (Cox, 1987), The U.S. Centers for Disease Control and Preven tion (CDC) states that the number of mycobacteria that are expelled into the air from a person with tuberculosis correlates with a number of factors, to include the presence of cough or other forceful expirational maneuvers, and the willingness or ability of the patient to cover his or her mouth when coughing (MMWR, 1990). Particles larger than droplet nuclei that settle out from the air can potentially be reen trained back into the indoor air follow ing decreased size due to droplet evaporation, in combination with an aerosol generating activity such as making a bed. Aerosol chamber studies have demonstrated the aerial dispersion of Siaphylococcus aureus from the activity of a colonized operating room technician linked to wound infection in eleven patients (Tanner et al., 1980). Environmental Source Airborne opportunistic infectious disease microorganisms emanating from a variety of environmental sources have long been a concern in regard to nosocomial infection and hospital infection control. Susceptible health care and related workers are also at risk of infection from such agents. While person-to-person transmission has not been documented, Legionnaires disease has occurred from exposure to aerosols generated from contaminated cooling towers (Dondcro et al., 1980; Garbe et al., 1985).

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Aerosol Characterization Eugene C. Cole, Dr.P,H.


Additionally, the causative agent, Legionella pneumophila , has been isolated from aerosols produced by water faucets and shower heads (Bollin et aJ., 1985), humidifiers and nebulizers (Araow et al., 1992), and by squeezing manual ventilation bags (Woo et al., 1986). Sources of Aspergillus spores in health care facilities have been identified as outdoor construction (Sambbi et al., 1982), indoor construction and ceihngtile (Strcifel, 1988), air conditioners (Wadowsky and Benner, 1987), and contaminated carpet (Hunt, 1987). Other potential environmental sources of Aspergillus are components of healing, ventilation, and air-conditioning (HVAC) systems, to include contaminated filters, condensate, cooling coils, air intakes, and porous insulation in air ducts. B io aero so l Size a n d A erodynam ics Infectious bioaerosol particles may exist as 1) single bacterial cells or spores, fungal spores, or viruses; 2) aggregates of several cells, spores, or viruses; or 3) as biological material carried by other, non-biological particles (Nevalainen et al., 1993). Micro organisms span wide size ranges. In general, infectious microor ganisms will range from 0.3-10 pm for bacterial cells and spores, 2.0-5.0 pm for fungal spores* and 0.02-0.30 jjun for viruses. Specific pathogen sizes include 0.3-0.6 X 1-4 pm for M. tubercu losis (Wayne and Kubica, 1986); 0.3-0.90 x 2.0-20 |tm for Legionella pneumophila (Brenner et al., 1984); 2.5-3.0 |4m for Aspergillusfumigatus spores (Samson and van Reenen-Hoekstra^ 1988); and 0.09*0.12 pm for influenza virus (Murphy and Kingsbury, 1990). Most infectious particles generated from human respiratory sources will occur primarily as droplet nuclei, 0.5-5.0 pm diameter (Owen and Ensor, 1992). As droplets are forcefully expelled from the respiratory tract they begin to evapo rate and thus change in respect to their mass and aerodynamic diameter. Upon complete evaporation, the particles may be small enough to remain airborne in the indoor air flow. As pointed out almost sixty years ago, the size of droplet nuclei depends on the amount of solid matter contained in the evaporating droplet (Wells, 1934). Microorganisms however are hygroscopic, and so

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Aerosol Characterization Eugene C. Cole, Dr.PH.


the relative humidity of an indoor environment can have a dra matic effect on the particles aerodynamic size, length of time airborne, and viability. The latter is extremely important, as only a viable microorganism can initiate an infectious process. Gravi tational, thermal, and electrostatic fields also affect the aerody namic behavior (Cox, 1987). B io aero so l Infectivlty a n d V irulence The infectious disease process in an animal host is a function of microorganism concentration (infective dose) and virulence (dis ease promoting factors) that enable an agent to overcome the normal physical and immunological defenses of the host. For humans, the initiation of some microbial diseases requires only small infective doses, as the agents have affinity for specific tissue, and possess one or more potent virulence factors that render them resistant to inactivation. For example, infection with airborne Francisella tularensis (the causative agent of tularemia) is reported to result from a single microorganism, whose virulence is associated with a cellular capsule (Cox, 1987). Only a few cells of M . tuberculosis, with its unique and resistant cell wall structure, are required to overcome normal lung clearance and inactivation mecha nisms in a susceptible host Susceptibility increases through chronic exposure and decreased immune function that may result from a variety of natural or self-induced predisposing factors such as aging, crowded living conditions, heavy smoking, poor nutrition, alcohol ism* etc. Tuberculosis epidemics can occur among persons congre gated in enclosed spaces such as homeless shelters, nursing homes, hospitals, schools, prisons, and office buildings, Infectivity and the need for HV AC engineering controls forTB were demonstrated over thirty years ago. Experiments were conducted that exposed guinea pigs to air vented from a ward where TB patients were receiving drug therapy. Over a two year period, out of an average of 156 guinea pigs exposed continuously to the air from a six bed tuberculosis ward, 71 became infected (Riley et al., 1959). Viral infectivity and virulence is undoubtedly more readily no ticeable to the general public. Each year viral influenza epidemics

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Aerosol Characterization Eugene C. CoJe, Dr.PH.


sweep the globe, some with greater virulence than others. During major epidemics, influenza hospitalizations for high-risk persons may increase 2-5 fold (MMWR, May 1992), placing health care workers at increased risk of infection. Small infective doses are thought to be responsible due to the rapidity with which the disease spreads throughout a population. Couch et al. (1981) studied natural airborne transmission of respiratory infection with Coxsackie A virus type 21. Using two groups of adult volun teersone infected with the vims, and the other non-infccted and antibody freeseparated by a double walled, wire screcn four feet wide, transmission of infection was demonstrated on day six, as a wave of infection swept the previously non-infected group. Measles is a highly contagious viral disease that is spread by the airborne route. The infective dose is small, and as few as four doses per minute from an infected individual can initiate an epidemic (Riley, 1980), Additionally, rubella (German measles) and varicella (chicken pox) viruses can be readily spread via aerosols in indoor air, Aiibome fungi, most notably Aspergillus jum igatus and other species, are a very serious infectious disease threat to those who are immunocompromised due to immunosuppressive or cyto toxic therapy. Inherent in the infection process initiated by the inhalation of infectious droplet nuclei is the area of deposition within the respiratory tract. Such deposition is influenced by hygroscopicity, as an increase in the size of inhaled aerosols occurs through moisture take up as they move within the airways. Knight (1973) estimates that a 1.5 fim hygroscopic particlea common size in coughs and sneezeswill increase to 2,0 ^tm in diameter when passing through the nose, and to 4.0 |^n in the saturated air of the nasopharynx and the lung. He further theorizes that the effect of bygroscopicity and the resultant particle size change will increase retention in the tertiary bronchioles and alveolar ducts, an effcct that may be significant for virus aerosols that are highly infectious for that part of the lung.

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Aerosol Characterization Eugene C. Cole, Dr.P.H.


B io aero so l Viability an d C lim ate F a c to rs When pathogenic microorganisms leave their host and are aerosolized, they are potentially injured during the generation process. Additionally, once airborne they are outside of their natural habitat and, depending upon a variety of environmental factors, are increasingly subject to loss of viability over time. Viability can be defined as the capability of a microorganism to reproduce. Even if a microorganism remains alive yet cannot reproduce, it can be considered non-viable, for it has lost the ability to survive and reestablish a population within a defined environment. Factors influencing the survival of bioaerosols include their suspending medium, as well as temperature, humid ity, oxygen sensitivity, and exposure to ultraviolet or electromag netic radiation. Using a variety of bacteria, Wells (1934 b) generated data that indicated microorganisms could remain viable in the airborne state for periods that permitted their wide dissemi nation. Once aerosolized in the indoor environment, microorgan isms are subject to lethal desiccation, which results from an interplay of organism morphology, physiology, oxygen sensitiv ity, and suspending medium, with varying levels of humidity and temperature, in addition to air movements* pressure fluctuations, air ions, and other airborne pollutants (Cox, 1987). Thus, the survival potential of any given microbial pathogen when aerosolized is unique to that organism under those specific condi tions at that particular point in time. An assessment of environ mental factors relative to bacterial and viral survival in aerosols has been reviewed (Mohr, 1991). Tem perature and Relative Humidity Temperature and relative humidity are important factors in aero sol survival. The effects of varied relative humidities can be studied only when temperature is controlled- Many laboratory investigations have established, in particular, that the effect of relative humidity on airborne microorganisms is an important but unpredictable factor. Harper (1961) investigated the survival (for

58

Aerosol Characterization Eugene C. Cole, Dr.P.H.


up to 23 hours) of four viruses (vaccinia, influenza A, polio, and Venezuelan equine encephalomyelitis [VEE]) aerosolized at vary ing temperature and relative humidity (RH) in the dark. He found that, in general, virus survival at each RH was better at lower temperature than at higher temperature. In addition, vaccinia, influenza, and VEE viruses survived better at low RH (17^25%), while polio virus showed greatest survival at high RH (80-81 %). Miller and Artenstein (1967) studied the survival of three aerosolized human respiratory viruses (adenoviruses 4 and 7, parainfluenza 3) in static chambers at three relative humidities (20%,50%,80%) and found that the adenoviruses survived better at 80% RH, while the parainfluenza virus survived better at 20% RH. The studies were carried out with aerosols having mass median diameters of about 2.0 pm. Davis et al. (1971) conducted dynamic aerosol studies using adenovirus 12 at 28-30C and 89%, 51%, and 32% RH, and found that survival increased as RH increased, and that the same relationship was found for the recovery of the virus from the lungs of exposed newborn ham sters. Schaffer etal, (1976) investigated effects of different means of virus propagation (cell cultures, egg cultures) on stability of influenza A virus at mid-range RH (50-80%), and showed varying survival as a factor of method of propagation. More recently, Ijaz and colleagues (1985) looked at survival of airborne human coronavims 229E at different conditions of temperature (20*C and 6C) and RH (30%, 50%, 80%), and found that maximum survival of the aerosolized virus was very much temperature dependent at 80% RH, All of these studies, as well as many others, indicate that the role of the environment on the survival of airborne microorganisms is extremely complex, and that for practical application to the control of airborne infectious agents, research must move from the laboratory test chamber to the actual indoor environment using previously developed standardized techniques and approaches.

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Aerosol Characterization Eugene C. Cole, Dr.P.H.


ENVIRONMENTAL SAMPLING AND ANALYSIS All existing methods of bioaerosol sampling are potentially appli cable to the recovery of infectious disease agents from indoor air. Detailed reviews of bioaerosol sampling methodology arc avail able (Cox, 1987; Fradkin, 1987, Chatigny, 1983). Sampling focuses primarily on the recovery of viable microorganisms using methods of impingement, impaction, filtration, centrifugal sepa ration, or electrostatic and thermal precipitation. All bioaerosol samplers will fatally damage some portion of the total microor ganisms collected. Such injury may occur through impaction onto culture media, other surfaces, or through sampler wall losses, turbulence in impingement fluid, desiccation on filter media, etc. Organism loss is also related to the rate of flow of air sampled. A filter method may sample at a rate of four liters per minute, while an all-glass impinger samples at a rate of 12.5 1/min, a sieve impactor at 28.31/min, a high volume impactor at 180 l/min, and other high volume samplers at hundreds or thousands of liters per minute. All samplers must be calibrated as to flow rate prior to use, and their collection efficiencies as a function of particle size and shape established previously. Collection efficiencies are typically determined in controlled laboratory studies using particles of known size and shape under controlled conditions. A laboratory study of collection efficiencies of commonly used bioaerosol samplers was recently published (Jensen et ah, 1992); and the physical factors affecting the performance of bioaerosol samplers, particularly in regard to the concept of stopping distance, have been intensively addressed (Nevalainen et al.5 1992). Comparative sampler performance evaluations have also been conducted under field conditions with natural aerosols (Lundholm, 1982). Recent aerosol research has described the inlet sampling efficiencies of several commercial bioaerosol samplers, as well as the design of a single stage impactor that can be used to study different sampling and analysis variables, such as relative humidity, sampling flow rate, and desiccation time, which affect bioaerosol viability (Willeke et al.,

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Aerosol Characterization Eugene C, Cole, Dr.P.H.


1993). Such research can be critical in identifying sampling instruments and techniques to recover infectious agents that might be particularly sensitive to collection, and are present only in small numbers in the indoor air, as perhaps M . tuberculosis . Efficient aerosol sampling methods and techniques for the collection of Af tuberculosis from indoor air have not yet been described. Other airborne mycobacteria have been successfully recovered from the outdoor air however, using impactor samplers with specified, enriched media (Falkinhametal., 1990), A variety of aerosol sampling techniques and analysis procedures have been used for the recovery of human viruses and have been reviewed (Chatigny, 1983; Sorber, 1987)* The scope of the problem of sampling for airborne pathogens is exemplified by research results (Gerone et al 1966) with natural aerosols of Coxsackie A-21 virus. It was found that if individuals harbored 104TCID5 0ofvirus per milliliter of oral secretions, sneezed 100 times in a closed room (70,000 liters), and atomized 5,9 x 10* ml of secretions with each sneeze, 12,000 liters of air would have to be sampled to recover one TCID^ of virus. Analysis of collected samples is no longer restricted to the collection of bioaerosols for culture for viability. New tech niques, as commonly used in the clinical microbiology laboratory now have application to environmental monitoring, particularly when the goal is demonstration of airborne infectious agents. A variety of techniques, such as fluorescent antibody, monoclonal antibody, gene probe, and polymerase chain reaction (PCR) now afford other isolation and identification/confirmation options, particularly as rapid analysis and assessment of the indoor air becomes increasingly more important. While bioaerosol recovery and rapid analysis methods and techniques have been addressed (Morey et al., 1990), much research remains to be done in order to refine and standardize those optimum procedures that will prove effective in regard to the characterization of infectious disease aerosols.

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Aerosol Characterization Eugene C. Cole, Dr.P.H.


RESEARCH NEEDS AND RECOMMENDATIONS Needed bio aerosol research directed toward the development, implementation, and evaluation of effective engineering controls for preventing airborne infections in workers in health care and related facilities requires basic and applied investigation. Re search goals include 1) selection and evaluation of appropriate model or surrogate pathogens for each of the major groups of infectious disease microorganisms of concern (e.g., mycobacte ria, respiratory viruses); 2) evaluation of existing and experi mental sampling methods or techniques for the recovery of selected model microorganisms; 3) on-site evaluation of existing individual or combined engineering controls using selected model microorganisms and recommended aerosol recovery techniques; and, 4) evaluation of experimental engineering controls and/or pathogen detection devices using selected model microorganisms and recommended aerosol recovery techniques. M odel M icroorganism S e lectio n an d E valuation Regardless of laboratory and aerosol test chamber data indicating the effectiveness of specific engineering controls, such potential applications must be eventually evaluated in actual indoor envi ronments. Such studies in unoccupied buildings would require the aerosolization of one or more suitable model or indicator microorganisms. Such organisms would be required to be nonpathogenic to humans, to be related to the target human pathogen and possess similar aerosol and inactivation kinetics, and to be recoverable from the indoor air. The selection of such organisms would follow the identification from the literature of potential candidates, with subsequent chamber characterization in the aerosolized state, to include assessment of potential recovery techniques. For example Mycobacterium phlei would appear to be a candidate model organism for use in evaluating indoor engineering controls for preventing the airborne transmission of tuberculosis. M . phlei is non-pathogenic for humans, is a rapidly growing and pigmented environmental Mycobacterium , and has
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Aerosol Characterization Eugene C. Cole, Dr.P.H.


been found to be ten times more resistant than virulent Af. ro6erc/ajwbaci!!itoultravioletradiation(RileyetaI., 1976). Its generation as an aerosol, perhaps in artificial sputum, would need to be assessed in the laboratory relative to its resultant airborne characterization. Additionally, the appropriate collection me dium and bioaerosol samplers) would also need to be identified. Similarly, model viruses and their recovery techniques could be selected for use in evaluating potential engineering controls in indoor environments. Aerosolized murine influenza viruses have been used as an infectious respiratory disease model (Fairchild and Roan, 1972), and poliovirus type 1and simian rotavirus SAI 1 have been used to assess germicidal effectiveness of UV light (SattaretaL, 1984). Bacteriophages have long served as excellent models for disinfection studies relative to the inactivation of human viruses in water and wastewater. Research is needed to identify those bacteriophages that might serve as models of infectious human respiratory viruses in indoor air studies aimed at evaluating engineering controls. B io aero so l Sam pling M ethods Evaluation The recovery of selected airborne model microorganisms would need to be assessed in the laboratory in order that optimum samplers, sampling times, collection media, and incubation tem peratures and times are identified for each model microorganism. Both existing, available, bioaerosol samplers, and experimental bioaerosol samplers should be included. The most important aspect of this evaluation is the overall objec tive of the sampling. Unlike sampling indoor air for allergens or sensitizing microorganisms, the goal of recovering real or model human pathogens may be solely to demonstrate their presence or absence, as opposed to accurate quantitation per unit volume of air. Assuming that the goal of engineering controls for airborne human pathogens is to significantly reduce human exposure to them, and the presence of even one of them is unacceptable

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following air treatment, then the sampling and recovery research would need to focus on the collection of large and/or high volume samples to demonstrate the presence or absence of collected model organisms in a significantly large volume of indoor air. As indicated in the literature, the successful collection of natural microbial aerosols, because of their low concentrations, requires the sampling of large volumes of air (Cox, 1987). High volume sampling however, normally brings with it a higher potential for injury of microorganisms through the recovery process due to physical injury and/or desiccation from collection in a high flow rate air stream. Large volume (or long-term) sampling for extended time periods at a much lower flow rate also presents problems in regard to maintenance of viability of collected micro organisms over time. Research is needed to devise methods for the continuous sampling of bioaerosols. Existing Engineering Controls Evaluation Selected model microorganisms and sampling methods can be used to evaluate existing environmental engineering controls or combinations of controls for the prevention of transmission of infectious agents in the workplace. Three methods of air quality control are identified: source control, removal control, and dilution control (Woods and Rask* 1988). Source control minimizes contamination within an occupied space, such as a laminar flow bed providing local or source control for a newly diagnosed tuberculosis patient. Removal control utilizes various air cleaning devices to control particulates by either active or passive mechanisms. Active removal involves the use of devices with media filters or electronic air cleaners, such as the use of portable HEPA filtration units in the rooms of TB patients, while passive removal involves mechanisms such as particle settling, ton diffusion charging, thermophoresis, and coalescence (Woods and Rask, 1988). Dilution control involves the reduction of airborne contaminants by the introduction of less contaminated air into the occupied space, and may occur via natural or mechanical ventilation.

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Another air quality control that may be used in conjunction with other methods of particulate removal or dilution is ultraviolet (UV) air disinfection. The goal is to inactivate human pathogenic microorganisms in droplet nuclei in the air supplied to occupied spaces harboring potentially susceptible individuals. While it is recognized that different microorganisms vary in their susceptibility to UV, the application of the technology to control airborne TB in health care and other woik environments has been shown to be of value and is well described by Riley (1988) and Nardell (1988). ExpeiimenlalContn>lsA>evjce50evek)pniernandEvaluath>n The research and development of experimental bioaerosol engi neering control technologies may provide additional means of controlling infectious disease transmission in the indoor environ ment. For example, basic research on the use of pulsed high electric fields to inacti vate microoiganisms (Hamilton and Sale, 1967; Mizuno and Hori> 1988; Hayamizu et al., 1989) indcales the need for investigation of such a technique for potential applications to control airborne microbial contamination in air handling systems. While a variety of in situ optical techniques provide a powerful resource for the measurement of particle size distributions (Rader and CTHem, 1993), there are none at the present time that can differentiate viable biological particles from non-viable and/or non-biological ones. Dedicated research efforts aimed at the development of real-time devices to detect viable from nonviable/non-biological airborne particulates could in the near fu ture provide for continuous monitoring and thus early warning detection and/or control systems in health care and other related facilities. Such devices would theoretically be designed to use light scattering or other physical means to detect only airborne microorganisms of certain pathogen groups, such as cells of Mycobacterium , spores of Aspergillus, or perhaps even units of respiratory viruses. Further investigation is needed to demon strate the feasibility of the concept of light scattering to differen tiate viable biological particles from non-viable/non-biological

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ones. Basic light scattering studies using an electrodynamic balance have been published (Davis and Periasamy, 1982; Davis and Periasamy, 1985). IMPLEMENTATION OF RESEARCH RECOMMENDATIONS In the context of a national strategy, it is suggested that recom mended research, in the area of aerosol characterization relative to engineering controls for preventing airborne infections in workers in health care and related facilities, be implemented with consideration of the following; * Recognition that both basic and applied bioaerosol research programs are necessary to the achievement of the goal of prevention of airborne infections in specific worker populations* Coordination of all relevant federally funded basic and applied bioaerosol research programs to acceler ate achievement of defined goals, avoid duplication of efforts, and contain costs. Simultaneous initiation of both basic and applied bioaerosol research programs. For example, initial laboratory experimentation leading to the develop ment of a viable particle detector for airborne tubercle bacilli could run concurrently with applied efforts at identification of a model Mycobacterium to use to evaluate the effectiveness of existing engineering controls for eliminating the transmission of M . tuber culosis in indoor air. Minimization of start-up time and related costs through identification of, and cooperation with, individuals and organizations having existing expertise and fa cilities (e.g..aerosol chambers, aerosol engineers, microbiology laboratories) necessary to conduct bioaerosol research. Cooperation with standard setting organ izatio ns hav ing interest and relevance to aerosol characterization

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research, for example the American Society of Heat ing, Refrigerating, and Air-Conditioning Engineers (ASHRAE), and the American Society for Testing and Materials (ASTM); as well as professional asso ciations providing technical platforms for the discus sion and dissemination of technical research infor mation, such as the American Association for Aero sol Research (AAAR), and the American Industrial Hygiene Association (AIHA). REFERENCES AmowPM, ChouT, WeilD,ShapimENand KretzsclirnarC. Nosocomial Legionnaires disease caused by aerosolized tap water from respiratory devices. J, Infect. Dis, 1982; 146:460-467. Benenson AS. Control of communicable diseases in man. Wash ington DC: American Public Health Association, 1990. Bollin GE, Plouffe JFa Para MF and Hackman B. Aerosols containing L e g io n e lla p n e u m o p h ila generated by showerheads and hot water faucets. Appl. Environ. Microbiol. 1985; 50:1128-1131. Brenner DJ, Feeley JC, Weaver RE. Family VII. Legionellaceae. In: Holt JG, Krieg NR. eds. Bergeys Manual of System atic Bacteriology, Vol. 1. Baltimore:Williams & Wilkins, 1984:279-283. Catanzaro A. Nosocomial tuberculosis. Am. Rev. Respir. Dis. 1982; 125:559-562. Chatigny, MA. Sampling airborne microorganisms. In: Lioy, PT, Lioy, JY. Air Sampling Instruments for Evaluation of Atmo spheric Contaminants. Cincinnati: American Conference of Governmental Industrial Hygienists, 1983: E2-E9. Couch RB. Viruses and indoor air pollution. Bull. NY Acad. Med. 1981; 57:907-921. Cox CS. The Aerobiological Pathway of Microorganisms. Chichester: John Wiley & Sons, 1987. Davis EJ, Periasamy R. Single particle light scattering measure ments using the electrodynamic balance. Aerosol Science and Technology, 1982; 1:337-350.

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Davis EJ. Periasamy R. Light scattering and aerodynamic size measurements for homogeneous and inhomogeneous microspheres. Langmuir, 1985; 1:373-379. Davis GW, Griesemer RA, Shadduck JA, Farrell RL, Effect of relative humidity on dynamic aerosols of Adenovirus 12, AppJ. Microbiol. 1971; 21(4):676-679. Des PrezRM, HeimCR. Mycobacterium tuberculosis. In: Mandell GL, Douglas Jr RG, Bennett JE, eds. Principles and Practices of Infectious Diseases, 3rd ed. New York: Churchill Livingstone, 1990; 1877-1906. Dondero Jr TJ, Rendtorff RC, Mall ison GE, Weeks RM.Levy IS, Wong EW, Schaffner W. An outbreak of Legionnaires' disease associated with a contaminated air cooling tower. N. Engl. J, Med. 1980; 302:365-370. Falkinham JO, George KLSFord MA, Parker BC. Collection and characteristics of mycobacteria in aerosols. In: Money PR, Feeley Sr JCTOtten JA, eds. Biological Contaminants in Indoor Environments. Philadelphia: American Society for Testing and Materials, 1990:71-83. Fairchild GA, Roan J. Atmospheric pollutants and pathogenesis of viral respiratory infection. 1. evaluation of murine influenza as an infectious disease model. Arch. Environ. Health. 1972; 25:51-59. Fradkin A. Sampling of microbiological contaminants in indoor air. In: Taylor, JK, eds. Sampling and Calibration for Atmo spheric Measurements, ASTM STP 957. American Society for Testing and Materials, Philadelphia: 1987; 66-77. Gaibe PL, Davis BJ, Weisfeld JS, Karkowitz L, Miner P, Garrity F, Barbaree JM, Reingold AR. Nosocomial Legionnaires disease: Epidemiologic demonstration of cooling towers as source. JAMA. 1985; 254:521-524. Gerone PJ, Couch RB, Keefer GV, Douglas RG, Deirenbacher EB, Knight V. Assessment of experimental and natural viral aerosols. Bacteriological Reviews. 1966; 30(3)576-584. Hamilton WA, Sale JA. Effects of high clectric fields on microorganisms-II. Mechanism of action of the lethal effect. Biochem. Biophys. Acta. 1967; 148:801-811.
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Harper GJ. Airborne micro-organisms. Survival tests with four viruses. J. Hyg., Camb. 1961; 59:479-486. Hay amizu M, Temma T, Mizuno A. Destruction of yeast cells by pulsed high voltage application. J. of Institute of Electro statics Japan. 1989; 13(4):322-331. Hunt DL. Aspergillusflavus infection in a bone marrow transplant unit 31st Biological Safety Conference, Bethesda, MD; 1988. Ijaz MK, Brunner AH, Sattar SA, Nair RC, Johnson-Lusscnburg CM. Survival characteristics of airborne human coronavirus 229E. J. Gen. Virol. 1985; 66:2743-2748. Jensen PA, Todd WF, Davis GN, Scarpino PV. Evaluation of eight bioaerosol samplers challenged with aerosols of free bacteria. Am. Ind. Hyg. Assoc. J. 1992; 53(10):660667. Knight V. Viral and Mycoplasmal Infections of the Respiratory Tract. Philadelphia: Lea&Febiger? 1993:1-9. Lewis F. The risk of tuberculosis (TB) exposure in the workplace. Enviros, The healthy building newsletter. July 1992; Vol. 2, no. 7, attchmt IV, Lundholm, IM. Comparison of methods for quantitative determina tions of airborne bacteria and evaluation of total viable counts. AppL and Environ. Microbiol. 1982;44(1):179-183. Miller S, Artenstein MS. Aerosol stability of three acute respiratory disease viiuses. Proc. Soc. Exp, Biol. Med. 1967:222-227. Mizuno A, Hori Y. Destruction ofliving cells by pulsed high-voltage application. IEEE Trans, on IAS, 1988; 24(3):387-394, MMWR. Guidelines for preventing the transmission of tubercu losis in health-care settings, with special focus on HIVrelated issues. Centers for Disease Control, Atlanta. 1990; 39; RR-17. MMWR. Influenza - United States, 1989-90 and 1990-91 Sea sons, Massachusetts Medical Society, Waltham. May 1992; 41(SS)-3:35-46. MMWR. Transmission of multidrug resistant tuberculosis among immunocompromised persons in a correctional system. Massachusetts Medical Society, Waltham. July 1992; 41(28):507-509.

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Mohr AJ. Development of models to explain the survival of viruses and bacteria in aerosols. In: Hurst, CT, ed. Modeling the Environmental Fate of Microorganisms. Washington DC: American Society for Microbiology, 1991:160-190. Morey PR, Feeley Sr JC, Otten JA, eds, Biological Contaminants in Indoor Environments. Philadelphia: American Society for Testing Materials; 1990. Murphy FA, Kingsbury DW. Virus Taxonomy. In: Fields BN, Knipe DM, et al., eds. Fundamental Virology, 2nd ed,, New York:Raven Press, Ltd, 1991:9-35. Nardell EA. Ultraviolet air disinfection to control tuberculosis in a shelter for the homeless. In: Kundsin RB, ed. Architec tural Design and Indoor Microbial Pollution. New York: Oxford University Press, 1988:296-308. Nevalainen A, Pastuszka J, Liebhaber F, Willckc K. Performance of bioaerosol samplers: collection characteristics and sam pler design considerations. Atmospheric Environ. 1992; 26A(4):531-540. Nevalainen A* Willeke K, Liebhaber F, Pastuszka J, Burge H, HenningsonE.Bioaerosol sampling. In: Willeke K, Baron PA, eds. Aerosol Measurement. New York: VanNostrand
Reinhold, 1993 : 471492.

Owen MK, Ensor DS, Sparks LE. Airborne particle sizes and sources found in indoor air. Atmospheric Environment. 1992; 26A(12)2149-2162. Rader DJ, OHem TJ. Optical direct-reading techniques: In situ sensing. In: Willeke K, Baron PA, eds. Aerosol Measure ment. New York: VanNostrand Reinhold, 1993:345-380. Riley EC. The role of ventilation in the spread of measles in an elementary school. Am. NY Acad. Sei., 1980; 353:25-34, Riley RL, Mills CC, Nyka W, Weinstock N, et al. Aerial dissemi nation of pulmonary tuberculosis. A two-year study of con tagion in a tuberculosis ward. Am J.Hyg. 1959; 70:185-196. Riley RL, Knight M, Middlebrook G. Ultraviolet susceptibility of BCG and virulent Tubercle bacilli. Amer. Review of Resp. Dis. 1976; 113:413-418.

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Riley RL. Ultraviolet air disinfection for control of respiratory contagion. In: Kundsin RB, ed. Architectural Design and Indoor Microbial Pollution. New York: Oxford Univer sity Press, 1988:174-197. Samson RA, van Reenen-Hoekstra ES, et al. Introduction of Food-Borne Fungi. Baarn: Centraalbureau Voor Schimmelcultures, 3rded. 1988:64. Sarubbi JrFA, Kopf HB, Wilson MB, McGinnis MR, Rutala WA. Increased recovery o f Aspergillus flavus from respiratory specimens during hospital construction. Am. Rev. Rcspir. Dis 1982; 125:33-38. Sattar SA, Ijaz MK, Johnson-Lussenburg CM, Susan V. Effect of relative humidity on the airborne survival of rotavirus SA11. Appl. and Environ. Microbiol* 1984; 47(4):879-88L Schaffer FL, Soergel ME, Straube DC, Survival of airborne influenza vims: effects of propagating host, relative hu midity, and composition of spray fluids. Archives of Virology. 1976; 51:263-273. Schlossberg D., ed. Tuberculosis. New York:Springer~ Verlag, 1988:9-11. Snider D, In: Occupational Safety and Health Reporter, Oct 28, 1992:1125. Sorber CA. Recovering viruses from aerosols. In: Berg G, ed. Methods for Recovering Viruses from the Environment. Boca Raton:CRC Press, Inc., 1987:54-64, Streifei AJ. Aspei^illosis and construction. In: Kundsin RB, ed. Architectural Design and Indoor Microbial Pollution. New York:Oxford University Press, 1988:198-217. Tanner EISBullin J, Bullin CH, Gamble DR. An outbreak of post' operative sepsis due to a staphylococcal disperser. J. Hyg. Camb. 1980; 85:219-225. Wadowsky RM, Benner SM. Brief report: Distribution of the genus Aspergillus in hospital room air conditioners. In: Wenzel RP, Schaffner W, et al., eds. Infec, Control, Vol. 8, 1987:( 12)516-518.

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Wayne LG, Kubica GP. Genus Mycobacteriaceae. In: Holt JG, Sneath PHA, Mair NS, Sharpe ME, et al eds. Bergeys M anual of System atic B acteriology, Vol. 2. BaltimorerWilliams & Wilkins, 1986:( 16) 1436-1457. Wells WF. On air-borne infection. Study II. Droplets and droplet nuclei, Am. J, Hyg. 1934(a); 20:611-618. Wells WF, Stone WR. On air-borne infection. Study HI. Viability of droplet nuclei infection. Am. J. Hyg. 1934(b); 20:619-626. Willeke K, Grinshpun SA, Donnelly J, Juozaitis A, Thompson M, Chang C-W,LiebhaberF, andNevalainen A. Physical and biological sampling efficiencies of bioaerosol samplers. In: Proceedings of the 6th International Conference on Indoor Air Quality and Climate. 1993:(In Press). Woo AH, Yu VL, and Goetz A. Potential in-hospital modes of transmission of Legionella pneumophila . Demonstration experiments for dissemination by showers, humidifiers, and rinsing of ventilation bag apparatus. Am. J. Med. 1986; 80:567-573. Woods JB, Rask DR. Heating ventilation, air-conditioning sys tems : The engineering approach to methods of control. In: Kundsin RB, ed. Architectural Design and Indoor Micro bial Pollution. New York:Oxford University Press, 1988:123-153.

72

SOURCE CHARACTERIZATION ANDCONTROL

Prepared by:

James Melius, M.D., DrP.H. Director Division of Occupational Health and Environmental Epidemology New York Stale Department of Health Albany, New York

INTRODUCTION With the reemergence of tuberculosis as a major public health problem in the United States, the control of the transmission of airborne infections in health care facilities and other workplaces has received renewed attention. Not surprisingly, after years of neglect, we find that our scientific knowledge base in this area is very weak, and that control programs in many healthcare facilities are less than ideal. As a result of this ignorance, our attempts to improve our procedures and guidelines have been largely based on extrapolation from other areas rather than on data from direct studies of this problem. This extrapolation has lead to controversy and concerns about the soundness of these recommendations. One source of this problem in applying principles of occupational health prevention to the control of airborne transmission is the nature of the exposure being controlled. Most commonly in occupational health, we try to control an exposure resulting from a work-related process such as manufacturing a chemical or removing insulation from a building. However, in the ease of airborne infections, the major source of exposure (with some

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exceptions to be discussed below) is a person, usually a patient at a health care facility. In contrast to an industrial source which is usually relatively fixed and constant, the source of airborne infections is very dynamiche or she moves around and usually resists staying in one place or one position for very long. More over, the process that produces the airborne infection' is also very dynamic. Levels of production appear to increase and decrease with litde predictability, hardly a desired characteristic of a manufacturing process. Despite this unpredictable nature, we have been relatively suc cessful in the past at controlling exposure to airborne infections in health care facilities. I believe that most of our success in this area does not result from the usual techniques used in occupational health such as exhaust ventilation, personal protective equipment, etc. Rather, our colleagues in communicable disease and infec tion control have achieved this control by identifying potential sources of infection and isolating this potential source. This source identification and control has been a major accomplish ment and should be recognized as the key step in controlling transmission in health care facilities. Data from the major recent hospital outbreaks illustrate the tragic results when this process breaks down. Now there is much that is known (and unknown) about identify ing infectious patients and other sources of airborne infectious diseases. In summarizing that information for this paper, I have tried to follow the plan for this meeting of following traditional occupational health control approaches. While this may detract from easily summarizing some of this literature (particularly the clinical aspects), I believe that this translation into occupational health terminology will provide better integration with the rest of this conference and recommendations. I also have not tried to rigidly separate our scientific knowledge about these sources from the current status of control programs. The latter obviously depends on the former, and an artificial separation between the two is confusing.

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CURRENT KNOWLEDGE: AIRBORNE INFECTIONS IN HEALTH CARE AND RELATED FACILITIES D ise a s e s o f In terest There are many diseases which pose a potential risk for airborne spread in health care facilities. Obviously, almost any illness that is communicable via the airborne route may be transmitted to workers in a health care facility. The more important diseases include tuberculosis, varicella, rubella, rubeola, influenza, and aspergillosis. For the most part, these fall into two categories. The First category includes all illnesses whose major source is an infected patient in the facility. Given the current importance of tuberculosis, most of the discussion will focus on that illness. As tuberculosis is a chronic infection, the control of its source is much more complicated than for acute infections. Other diseases will be mentioned as examples, but many of the same research and control considerations also apply to those diseases. For the second category, aspergilla will be discussed in relation to environmental contamination and control. Although not important as a cause of illness in workers in health care facilities, aspergillosis is impor tant as a cause of illness in susceptible patients, and the transmis sion of the disease illustrates a disease where other environmental sources are the major source of transmission. The control of the spread of these diseases in health care facilities is also related lo the prevention of transmission from patient to patient and from staff to patient. Many of our current control programs are directed at all three types of transmission. Although this document focuses on transmission from patient to health care worker, these other types of transmission are critical to many of our control procedures. P atien t a s S o u rc e of A irborne Infection The major source for the transmission of airborne infections in health care and related facilities is from infected patients. The bacteria or virus is exhaled as respirable droplet nuclei when the

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patient talks, coughs, or sneezes. The time course for the produc tion of this infective particle varies with the type of infectious disease. For acute infections, such as rubella and rubeola, a fairly predictable time period is followed from incubation to pre-clinical infection to acute illness. Production of viral particles in the respiratory tract follows a predictable time course with infectivity decreasing as the disease resolves. For chronic infections such as tuberculosis, the production of infectious droplet nuclei may follow a more prolonged and much less predictable course with significant differences among pa tients in the number of organisms expelled into the air over a specific time period. There are several factors which determine the infecliousness of an individual (CDCt 1990). These include clinical factors and behavioral factors. Patients with laryngeal or pulmonary tuberculosis are usually more infectious than patients with extrapulmonary TB. Among those with pulmonary TB, people with cavitary disease are more infectious (American Thoracic Society, 1983). Although data are limited, people with concomitant HIV infection do not appear to be more infectious than those without HJV infection taking into account other factors (CDC, 1990). Patients who cough also appear to be more infectious, and the ability of the patient to cover their mouth while coughing modifies this risk. Procedures that may induce a cough in an infected person obviously increase the risk of transmission (more on this below). Treatment factors are also important. Administration of effective therapy to a patient decreases the infectiousness of the patient (Riley, et al., 1962, Rouilton et al., 1976). However, the time course for that reduction in infectiousness varies among patients depending on both personal factors and factors related to the treatment (Noble, 1981). Patients with multiple drug resistant (MDR) tuberculosis appear to be infectious longer after treatment has been started than those without drug resistant infections (Beck-Sague et al., 1992).

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E valuating th e Infectivity of P a tie n ts Determining whether or not a patient is infectious is obviously a key factor for identifying a potential source of transmission in a health care facility. However, determining this may be quite difficult due to the limitations of the currently available tech niques. Usually, these tests assess whether infectious microbes are present in the sputum or other bodily fluid from the patient. Other tests focus on the immune response of the patient to the infection. These tests evaluate whether or not a patient is infec tious by determining the stage of the patients infection. The most immediate method for evaluating potential transmission of airborne infection would be to evaluate the patient's sputum for the presence of such organisms. This procedure has traditionally been used for tuberculosis and is a critical step for identifying and monitoring the course of that disease (Des-Prez and Goodwin, 1985). Sputum is collected, placed on a slide and stained, and the slide examined under a microscope. Patients who are smear positive are known to be more infectious than those who are not and conversion to smear negative is used as a marker for response to therapy and considering the patient as no Longer infectious (Rouillon et al.t 1976, Noble, 1981). Recent outbreaks indicate that among culture positive patients, those that are also smear positive are much more infectious than those who are not (BeckSaguc ct al., 1992). Proper collection of a sputum sample is critical for this procedure, and procedures to induce a cough are often used. Due to the unpredictable production of infectious sputum in patients with TB, at least three smears are usually used. For the most part, this technique is used only for tuberculosis, not for the other illnesses transmitted by airborne route in health care facilities. Another evaluation of infectivity is the utilization of cultures to grow and identify the microorganism. This can be done for tuberculosis and for some of the other infectious diseases in this

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category. However, results often take several days or longer to complete, and antibiotic sensitivities (to identify drug resistant strains) may take even longer to complete. Although not as helpful in the immediate identification of the infected patient, cultures are critical to confirming the infection, identifying the specific type of microorganism, and determining sensitivity to treatment (Des-Prez and Goodwin, 1985). Immune response may also be utilized in determining whether or not a person is infected This can be done either through blood testing or skin testing. However, such testing is usually not helpful for determining the presence of an acute infection; presence or absence of an immune response must be interpreted with clinical information about the patients course, etc. and such responses are usually delayed. Nevertheless, such testing could be useful particularly with better techniques to identify acute infections. O th er P atient-R elated S o u rc e s of A irborne Infections While the major source for the transmission of airborne infections in health care facilities is from droplet nuclei exhaled from infected patients, there are some other patient-related sources. These sources are usually responsible for only occasional cases but can at times be responsible for local epidemics or be a significant source of risk for certain categories of health care workers. For tuberculosis, one significant source may be an open (usually draining) wound or abscess (Hutton etal., 1990). Manipulation of the wound or abscess by a health care worker (c.g.? debridement) can cause microorganisms in the wound to become airborne. A more common source of exposure occurs from medical procedures that may induce cough in infected patients or involve contact with the patient's respiratory tract. Transmission of tuberculosis has been reported with procedures involving close contact with the patients respiratory tract such as bronchoscopy and intubation (Catanzaro, 1982, Ehrenkranz and Kicklighter, 1972, Haley et al., 1989). Procedures that induce sputum

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production may also lead to the transmission of tuberculosis (BeckSague et al.,1992, CDC, 1989). The latter pose a risk for not only people in the room during the procedure but also for people entering the room at a later tune (prior to clearance of the droplet nuclei). Autopsies on infected patients present an opportunity for expo sure in the handling and manipulation of infected tissue. Cases of tuberculosis have been reported in these settings (Kantor et al., 1988, Lundgrenetal., 1987). E nvironm ental S o u rc e s of A irborne Infections Although many microorganisms capable of causing airborne infections may remain viable for a long period of time after being deposited on surfaces, they usually must become airborne in order to infect patients or employees. Therefore, for most airborne infections, surface contamination plays a minor role in the trans mission of the disease. A more important role for surface contamination is illustrated by aspergillosis. Aspergilla spores in the environment may be an important source of infection in a health care facility. For tuberculosis, studies of conversion rates in hospitals have found that surface contamination plays little role in the develop ment of infection (Rubin, 1991). However, tubercle bacilli may persist for long periods of time on surfaces. There have been ca<ie reports of people infected from contaminated bronchoscopes and from contaminated needles (Rubin, 1991). Howe ve r, such reports arc rare, and environmental surface contamination does not ap pear to be a common route of infection. On the other hand, environmental contamination is an important source of exposure for aspergilla. Nosocomial outbreaks have been associated with aspergilla exposure from a breakdown in a hospital ventilation system or from construction taking place in or near the health care facility (Amow et al., 1991, Rhame, 1991). Declines in endemic nosocomial infection rates have followed efforts to reduce spore counts by ventilation changes, filters, and

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other measures (Amow et al 1991). Nearly all cases of aspergillosis occur in significantly immunocompromised pa tients (e.g., bone marrow transplant patients). Hence while important as a nosocomial infection for hospital patients, aspergillosis has not been commonly reported in health care workers as a result of work-related exposures. However, it does illustrate the potential problems of ventilation systems contribut ing as a source for airborne transmission of infectious agents. CURRENT CONTROL PROGRAMS S o u rc e Identification Prompt identification of infected individuals is the cornerstone for the prevention of the transmission of airborne infections in health care facilities (CDC, 1990)* Once cases or suspected cases are identified, appropriate precautionary steps and procedures can then be initiated (isolation, etc.). This identification is Largely dependent on clinical signs and symptoms. Knowledge of the local epidemiology of the disease can be important (who is likely to be infected) as well as the usual presentation for the illness. For example, tuberculosis patients with HIV infection often present clinical signs and symptoms different from classical tuberculo sis. Health care facility workers involved in admitting patients need to recognize these different presentations. Laboratory testing is critical for the confirmation of the clinical suspicion. As discussed above for tuberculosis, examination of sputum smears is a key procedure for early and quick diagnosis. The ready availability of this procedure is necessary for assisting with prompt diagnosis. Long delays can lead to inappropriate isolation of hospitalized patients or to infected patients not being appropriately isolated. The limited sensitivity of this test also limits its utility for rapidly identifying infected patients. AFB cultures, while more sensitive, take much longer to complete limiting their use for immediate decision making.

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Other laboratory tests arc also useful. For example, chest X-rays are critical for the diagnosis of tuberculosis. Tests of immune reaction (blood orskin tests)canbe helpful in the diagnosisofthese conditions. Confirmation that a patient is no longer infectious is also critical for determining whether isolation procedures can be discontin ued, whether a patientcan be discharged, etc. As discussed above, this determination may be difficult for patients with tuberculosis because of the variable clinical course of the illness and the limited sensitivity of sputum smears for detecting infected individuals. The increasing incidence of drug resistant strains further compli cates this determination. S o u rc e C ontrol M ethods Many of the source control methods used for airborne infections are procedural rather than the mechanical methods used in the control of industrial exposures. One key control method is for infectious patients to cover their mouths when coughing. Since coughing is a major source of infectious nuclei, this procedure can markedly reduce the potential for transmission of infection to other individuals. The use of a respirator is also recommended when an infectious patient is outside of an isolation area (CDC, 1990). Keeping an infected patient in an isolation room as much as possible is also important as a method of source control." Proce dures to limit the need for them to go to other areas of the health care facility and to minimize the time spent in those areas are necessary. Compliance with isolation restrictions can vary. Patients may need to be isolated for long periods of time. Many hospitals have made efforts to improve this restricted environment by providing televisions, VCRs, etc. Mechanical means of infection control are important for proce dures that may increase the production of airborne nuclei (e.g., sputum induction) or that lead to increased exposure for health care facility employees (e.g., bronchoscopy). Enclosed booths

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Source Characterization and Control James Melius, MX)., DrPJi.


are the preferred procedure for sputum induction and aerosolized pentamidine administration. These booths need to be properly exhausted to ensure that airborne nuclei are not introduced into the room during or after the procedure. Exposures during bronchoscopy can be controlled with local exhaust systems although these systems have not been as widely implemented as the sputum induction booths. Im m unization a n d S creen in g One other form of control for airborne transmission is to immu nize the health care worker to prevent them from becoming infected. For example, for rubella, this is the major method of control in a health care facility to prevent infection in health care workers, and such immunization is mandated in many states. For tuberculosis, there is considerable uncertainty about the efficacy and indications for the use of BCG. Another procedure is to screen health care workers for evidence of infection. If they develop evidence of an infection, they can then be treated with prophylactic medication. This method has been widely used for tuberculosis (CDC, 1990). Appropriate skin testing procedures need to be followed. There are also difficulties with prophylactic treatment including poor compliance and ad verse reactions to the medications. MAJOR ISSUES, PROBLEMS, OR RESEARCH GAPS Based on this review of our current state of knowledge, there are several major issues related to the identification and control of sources of airborne transmission of tuberculosis in health care facilities. Two major issues critical to control will not be discussed as they are beyond the scope of this meeting. Obviously, better control of the community epidemic of tuberculosis, rubeola, etc. will help to control the risk in health care facilities. Secondly, the development of better treatments for these conditions would also greatly assist in the control of transmission in health care facilities.

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B etter M ethods for th e identification of Infectious P atien ts The prompt and accurate identification of infectious patients is critical for the prevention of the transmission of airborne infec tions in health care facilities. Current methods are not sensitive, may not identify early stages of infection, or may take too long to process to be useful in many situations. Current research is developing better methods. For example, for tuberculosis, more sensitive and faster techniques for detecting tubercle bacilli on smears and cultures are currently being developed and introduced (Wilson et al., 1993,Abe et al., 1992, Crawford et al., 1989). After treatment has started, it is also important to know when a patient is no longer infectious. This is especially important for tuberculosis where long term treatment is required. Although this determination may be similar to identifying an infectious patient, different considerations of sensitivity and specificity may apply, and a rapid test may not be as critical. M eth o d s for Q uantitating In fe c tlo u sn e ss Currently, all patients with infections capablc of airborne trans mission are essentially handled the same in terms of judging their potential infcctiousness. There are some exceptions to this approach based on clinical indications. However, currently available methods do not provide a good way of assessing differences in infectiousnessdespite evidence that there is considerable variability in infectiousness between different patients with similar clinical findings. A method of determining the production of infectious nuclei by a patient would be extremely helpful for determining the type or degree of isolation for a patient and for decisions on respirator use and other administrative control measures. Ideally, a method needs to be developed to measure air levels of infectious particles. With polymerase chain reaction and other very sensitive (and specific) techniques, the development of such a method should be feasible (Wilson et al., 1993). Even if such a

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method were only available on a research level, valuable informa tion on the relative efficacy of different control procedures could be obtained (e.g., efficacy of different ventilation designs). M ore R e se a rc h U sing C urrent M ethods o n Identifying In fectio u s P a tie n ts The current epidemic provides an opportunity for developing better information on the identification of infectious patients using current methodologies. Much of this information will be gained from monitoring the skin test conversion rates of employees in health care facilities and relating this to their exposure to infected patients, use of control procedures, etc. While it is unfortunate that these workers are becoming infected, it is critical that we learn as much as we can from this experience. Much of the recently available data have been derived from epidemics among health care facility employees and/or patients (Beck-Sague et al., 1992, CDC, 1989). In nearly all of these situations, many different aspects of the control programs in those facilities have broken down, making it difficult to isolate the efficacy (or lack thereof) of individual control procedures. We must also monitor conversion rates, etc. in other health care facilities with less pronounced problems. This monitoring must be long term, must carefully document the implementation and use of control proce dures, and must follow standardized testing procedures. Workers in other types of health care facilities or occupations where there may be considerable contact with infectious individu als must also be evaluated. These include a number of healthcare and related areas which provide service for people at high risk of tuberculosis. Important ones include emergency rooms, home health care, outpatient clinics, drug and alcohol treatment facili ties, homeless shelters, and correctional facilities. Others may be noted through our surveillance efforts. Information from the clinical follow-up of infected patients must also be pursued. For tuberculosis for example, it would be useful to know how many patients discharged based on current criteria (e.g., three consecutive negative smears, etc.) are still infectious and

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what factors contribute to this infection rate. Better clinical followup of infected patients is currently underway, and it is important that this type of information be obtained from this fdlow-up. Im plem entation of B etter P ro g ra m s to Identify Infec tio u s P a tie n ts From the experience in New York and other areas, it is clear that much needs to be done to improve the identification of TB infected patients in health care facilities. This includes better availability of diagnostic services and better protocols for identi fying potentially infectious patients. For settings such as emer gency rooms, this can be done through protocols for the identifi cation of potentially infected patients and then the implementa tion of special procedures Jbr isolating and testing these patients. This approach needs to be extended to other types of facilities where care may be provided for "high risk groups (extended care facilities, home health care, homeless shelters, etc.) D evelopm ent of Im m unizations Immunization of susceptible individuals is a key method for protecting employees from the transmission of some airborne infections (e.g., rubella). The development of effective immuni zation methods for other diseases could be the most effective method for preventing transmission to employees in health care facilities. Health care workers in some countries are routinely given BCG to protect against tuberculosis. However, the efficacy of BCG for the protection of employees from TB transmission is unclear (Lugosi, 1992, Collins, 1993). This needs to be reevalauted and better methods developed. S u scep tib ility Immunocompromised individuals are more likely to be infected from exposure to infectious droplet nuclei (CDC, 1990). This has been clearly documented in the incidents involving the nosocomial

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transmission of tuberculosis to HIV-infected patients and in the occurrence of aspergillosis in patients receiving bone transplants, etc. (CDC, 1990, Rhame, 1991). HIV-infected healthcare workers also appear to be at greater risk in these settings (CDC, 1990). A better understanding of indicators of susceptibility to these infections would be useful for protecting workers from the air borne transmission of these diseases. Such information could be useful for individuals to make decisions about their personal risk and to take steps to further prevent exposures. B ehavioral F a c to rs Many of our measures to control the spread of airborne infections will be dependent on patient compliance, particularly for chronic illnesses such as tuberculosis. Ensuring that patients cover their mouths when coughing, wear respirators, remain in isolation rooms, etc. is difficult when these behaviors must be maintained for long periods of time. Many of the infected people have many other personal problems (drug addiction, etc.) and are likely to resist many of these requirements. Efforts are needed to develop and evaluate programs to improve compliance with these efforts. S p ecial P ro c e d u re s Procedures that may induce cough or involve contact with the patient's respiratory tract can increase the risk of airborne disease transmission. Cough induction procedures (sputum induction, aerosolized pentamidine administration, etc.) can be done in enclosed booths. Some of these have systems that filter the air through HEPA filters prior to returning the air to the general room area or exhaust the air outside the room. The efficacy of these units needs to be evaluated. Bronchoscopy and similar pulmonary procedures also pose some risk of airborne disease transmission. Given the potential for very high exposures to infectious droplet nuclei during these procedures, general room ventilation is prob ably not adequately protective even if increased to very high levels. Local exhaust systems appear to be a good alternative, but
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these must meet a number of criteria. They must provide adequate capture without interfering with the procedure. Placement during the procedure is also critical. Better systems for these procedures must be designed and implemented. Another area where special source controls may be useful involves the transport of infectious patients from isolation rooms to other areas of the health care facility for diagnostic procedures, etc. Current policies recommend the use of a respirator by the patient. Special tents or hoods to cover the wheelchair or stretcher might be useful, providing that adequate filtering was used and patient comfort provided. D isinfection Although not the major mechanism for the spread of most air borne infections, surface contamination may account for some cases. A better understanding of approaches to disinfection may help to prevent unnecessary transmission of these infections and possibly lead to new control measures. For example, one method of disinfection for tuberculosis, ultraviolet light is now used for general room disinfection. Perhaps other disinfectants could be used in similar ways. RESEARCH AND CONTROL PROGRAM NEEDS Based on the issues discussed above, several priorities for re search and control programs can be identified: R e se a rc h N eeds Research is needed to develop better methods for diagnosing infections capable of airborne transmission in health care and similar facilities. This need is particularly critical for tuberculosis where long delays between specimen collection and culture results may significantly delay the identification of patients. These methods need to be more sensitive and more rapid

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than current methods. A rapid test to identify potentially infectious patients would be very useful as well as quicker methods for identifying drug resistant organisms. Research is also needed to develop a better method for quantifying the infectiousness of an infected pa tient, Patients differ in their infectiousness, and current assessment of this infectiousness depends on general clinical criteria. A method to directly measure infectiousness would be very useful. The development of a method to measure air concentrations of infectious droplet nuclei should be feasible using techniques such as polymerase chain reactions (PCR). Even if this method was only available for research purposes, valu able information about the efficacy of isolation proce dures, ventilation, etc. could be obtained. Although current methodology has significant limi tations in identifying infectious patients, tracing the source of an infection, etc., large numbers of workers in health care and related facilities are being exposed to tuberculosis and other airborne infections. Fol low-up studies of these workers need to be under taken in order to better understand the sources of airborne infections and the efficacy of current control procedures. These studies need to be extended to include workers in other settings including home health care, drug and alcohol treatment centers, home less shelters, and other types of workplaces where workers may be exposed to airborne infections. The use of immunizations is an important method for protecting health care workers from certain airborne infections. For other types of infections, methods are not available or there is uncertainty about their effec tiveness. Better immunizations need to be developed especially for tuberculosis.
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Protecting health care personnel during special pro cedures such as sputum induction and bronchoscopy involves the utilization of special ventilation booths and local exhaust systems. These control methods need to be evaluated and better control methods developed for these procedures. Maintaining infectious patients in isolation for long periods of time will be difficult. The evaluation of factors related to compliance and methods to improve compliance with isolation procedures would be very helpful. Although some organisms capable of airborne trans mission may remain viable for long periods of time on surfaces, this is not an important source of trans mission except for aspergillosis (and then only by the microbe becoming airborne). However, a better understanding of the possible role of this potential source of infection as well as methods of disinfection would be helpful. Health care workers with impaired immune systems are more susceptible to airborne infections. A better understanding of the indicators of susceptibility would be useful for their personal decision making regard ing the use of protective measures, etc.

C ontrol P ro g ram N eed s Health care and related facilities need to develop and implement programs for the rapid identification of patients who may be infectious. These programs need to include procedures for expediting diagnostic testing on these individuals and must include the ready availability of screening tests such as AFB smears. Regional programs may be needed to expedite more complicated tests such as drug susceptibility testing.

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Surveillance systems must be in place through local and state health departments to facilitate the identifica tion of patients known to be infected by the appropriate sharing of this information with health care providers. Special procedures such as bronchoscopy and spu tum induction must only be carried out in areas with proper local exhaust or other ventilation. Training is critical both for the education of patients about ways that they can limit the transmission of their disease as well as for health care workers on ways that they can reduce their risks.

REFERENCES Abe C, Hosojima S, Fukasawa Y, Kazumi Y, Takahashi M, Nirano K* and Mori T, Comparison of MB-Check, B ACTEC, and eggbased media for recovery of mycobac teria. J Clin Microbiol 1992; 30:878-881. American Thoracic Society, Centers for Disease Control. Control of tuberculosis. Am Rev Respr Dis 1983; 128:336-342. Arnow PM, SadighM, Costas C, Wei] D, Chudy R. Endemic and epidemic aspergillosis associated with in-hospital repli cation of aspergillus organisms. J Infect Dis 1991 ;99:9981 0 0 2 .

Beck-Sague C, Dooley S W, et al. Hospital outbreak of multidrugresistant Mycobacterium tuberculosis infections. Factors in transmission to staff and HIV-infected patients. JAMA 1992; 268: 1280-1286. Catanzaro A. Nosocomial tuberculosis. AmRevRespirDis 1982; 125:559-562. Centers for Disease Control. Guidelines for preventing the trans mission of tuberculosis in health care settings, with spe cial focus on HIV-related issues. MMWR1990;39:1-29. Centers for Disease Control. Mycobacterium tuberculosis trans mission in a health clinicFlorida, 1988. MMWR 1989; 38:256-264.

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Collins FM. Tuberculosis: the return of an old enemy. Grit Rev Microbiol 1993; 19:1-16. Crawford JT, Eisenach KD, Bates JH. Diagnosis of tuberculosis: present and future. Semin Respir Infect 1989;4:171-181. Des-Prez RM Goodwin RA. Bacterial Diseases: mycobacteria] diseases: Mycobacterium tuberculosis. In: MandellGL, Douglas R, Bennett JE. Principles and Practices of Infec tious Diseases, 2nd ed. New York: John Wiley & Sons, Inc. 1985, Ehrenkranz NJ, Kicklighter JL, Tuberculosis outbreak in a general hospital: evidence of airborne spread of infection. Ann Intern Med 1972; 77:277-382. Hutton MDt Stead WW, Cautben GM, et al. Nosocomial trans mission of tuberculosis associated with a draining tuber culous abscess. J Infect Dis 1990; 161:286-295. Haley CE, McDonald RC, Rossi L, et al. Tuberculosis epidemic among hospital personnel. Infect Control Hosp Epidemiol 1989; 10:204-210. Kantor HS, Poblete R, Pusateri SL. Nosocomial transmission of tuberculosis from unsuspected disease. Am J Med 1988; 84: 833-838. Lugosi L. Theoretical and methodological aspects of BCG vaccine from the discovery of Calmette and Guerin to molecular biology. A review. Tuber Lung Dis 1992; 73:252-261. Lundgren Rt Nonrman E, Asberg I, Tuberculous infection trans mitted at autopsy. Tubercle 1987; 68: 147-150. Noble RC. Infectiousness of pulmonary tuberculosis after starting chemotherapy: review of the available data on an unre solved question. Am J Infect Control 1981; 9: 6-10, Rhame F, Prevention of nosocomial aspergillosis. J Hosp Infect 1991; 18:466-472. Riley RL, Mills CC, OGrady F, Sultan LU, WittstadtF, Shivpuri DN. Infectiousness of air from a tuberculosis ward. Amcr Rev Respir Dis 1962; 85:511-525. Rouillon A, Perdrizet S, Parrot R. Transmission of tubercle bacilli: the effects of chemotherapy. Tubercle 1976; 57: 275-299.

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Rubin J, Mycobacterial disinfection and control, Chapter 23. In: Blockt SS, ed. Disinfection, Sterilization, and Preserva tion. Philadelphia: Lea and Febiger, 1991. Wilson, SM, McNerney R, Nye PM, Godfrey-Fausett, PD, Stoker NG, and Voller A. Progress toward a simplified poly merase chain reaction and its application to diagnosis of tuberculosis. J Clin Microbiol 1993; 31: 776-782.

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BUILDING DESIGNS

Prepared by:

Georgeann Bums Principal The Austin Group White Plains, New York

WHERE WE AREBACKGROUND The context of this workshop is complex and of grave concern to those involved in health care: A growing number of newly diagnosed cases of tuberculosis (TB) in the general population of the United States* 32 recent deaths due to multidrug-resistant (MDR) TBmany of which were the result of nosocomial infections (CDC, 1991). And the fact that 23 % of the New York Stale inmate population has tested positively for TB (Greifinger, 1992).

While inner city hospitals have faced the growing numbers of TB patients, the majority of the nation* s health care facilities have not Focus throughout tbe country has rested largely on developing the appropriate responses to acquired immuno-deficiency syndrome (AIDS) and other major public health issues. These include continuing efforts to combat and treat cancer, substance abuse, infant mortality and cardiovascular disease. Coupled with in creased efforts to control capital and operating expenditures for health care and the subsequent move toward health care reform, little attention has been left for an affliction largely unknown by
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many Americans other than a threat from times past. In addition, past efforts to slow or limit increases in health care expenditures, such as construction moratoria and certificate of need processes, have increased the extent of our aging health care infrastructure. And, because of changing health care needs, delivery patterns and funding, TB sanatoria have long been abandoned as have many of the nations state-run psychiatric centers. Newer facilities with energy efficient mechanical systems have allowed potentially dangerous concentrations of TB through the use of recirculated air (Iseman, 1992). The public awareness of the return of tuberculosis as a major public health threat has been so relatively recent and limited that very little attention has been paid to building design as a specific response. An indicator of the relative concern about TB and its impact on facilities can be seen in a review of recent health care industry journals and publications such as Health Facilities Management, M odem Health Carey and Hospitals . Very few feature articles on facilities dealing with TB have appeared, with the roost notable article appearing in Health Facilities Management which emphasized ven tilation requirements and options (Neill, 1992). Itis the opinion of the writer that only two programs out of approximately one hundred will address any TB-ielated issues at the upcoming International Plan ning, Design and Construction Symposium sponsored by Ameri can Society of Hospital Engineers (ASHE). Within general acute care institutions such as hospitals and medical centers, the majority of attention regarding the isolation needs of patients have dealt with AIDS patients and others with immunosup pression and their need to be protected from opportunistic disease. Thus, in may facilities, the emphasis has been on protective isolation. In general, pediatric facilities have been more concerned about infectious isolation and limiting nosocomial infections. Thus the perceived need for infectious isolation facilities has not been high. In fact, it is the writers observation that many facilities regard the need for full-blown protective and infectious isolation

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rooms with anterooms to be largely unnecessary especially in light of the move toward greater percentages of, if not total, private patient accommodation. Only in 1992 did the American Hospital Association (AHA) issue a member briefing specifically focused on TB (Technical Panel on Infections Within Hospitals, 1992). Our charge is to develop a research agenda which will support the protection of health care workers fromTB. The risk has increased because of, according to one team, various cough-generating procedures used with AIDS patients (Nardell, 1990). In preventing the airborne transmission of TB, the greatest impact is generally on the patient And many ofthe traditional measures to combat or contain TB appear to ignore concerns about patient autonomy, ranging from involvement in medical decision-making and limited inpatient stays to control over ones individual environment in the health care facility. One of our challenges, or that of those who take up the implementation of our agenda, is to address public health needs effectively without totally losing sight of individual patient needs. Many patients, after initial diagnosis, do not require inpatient hospitalization for medical management (Stead, 1992, Berkow and Fletcher, eds*,1987). However, many others do. They include those with conditions requiring other supportive mea sures not possible on an outpatient basis and those with multidrugresistant TB. There are now also increasing numbers of patients who are not compliant in terms of continuing medication and observing proper infection control precautions. Recommenda tions have been made to consider involuntary confinement for non-compliant patients during the chronic phase of their illness not just during the time when they are infectious (Rothman, 1992). It is because of these patients that the concerns for other patients and staff arise. These patients already have and will continue to tax the available isolation facilities. The lack of adequate numbers of acid-fast bacilli (AFB) isolation rooms was clearly implicated in the recent outbreaks of nosocomial TB (CDC, 1991).

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In response to the Centers for Disease Control7s (CDC) published guidelines for control of TB transmission (CDC 1990), it appears that the primary focus of building design in this area should be isolation facilities within health care institutions. CDC recom mendations for the medical management of infectious patients requiring hospitalization include the use of AFB isolation precau tions (CDCt 1991). CDC indicates that this includes use of isolation rooms with requirements which mirror those listed in the American Institute of Architects (ALA) Guidelines (ALA, Com mittee on Architecture for Health, 1993), The ALAs Guidelines document does not specifically address TB as an infectious agent but does provide space and engineering requirements for infectious isolation rooms. These requirements include the use of a private room with negative air pressure in relation to surrounding areas and a minimum of six air changes per hour. All air is to be exhausted directly to the outside in such a way that it will not become pulled into supply intake vents for any area of the facility. Guidelines also indicates the need for an anteroom of 20 net square feet directly adjoining the intensive care isolation room and serving as a buffer between the isolation room and the general corridor (AIA, Committee on Architecture for Health, 1993). Additional CDC recommendations indicate the need for the use of disposable particulate respirators by staff entering the isolation room (CDC, 1991). The use of surgical masks by the patient when he or she is required to leave the isolation room while still infectious has been instituted in at least one New York City hospital (Pearson et al., 1992). While cohorting of patients and sharing of anterooms is not acceptable because of potential superinfection of MDR TB, one group feels that private rooms with positive air pressure can be used with window exhaust fans (Lutwick et al., 1992).

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While the major facility response at the end of the Last century and earlier in this century was the sanatorium (Dubos and Dubos, 1992), concerns about staffing, duplication of services and avail ability of specialized diagnostic and treatment equipment have argued against single-disease facilities as a current-day solution (Rothman DJ, 1992, Rothman SM, 1992). Thus, the continued development of hospital- and medical center-based inpatient isolation facilities is advised. However, these need to accommo date both acute care patients as well as intensive care patients. In addition, prison infirmaries should include AFB isolation rooms (CDC, 1992d, Glaser and Greifinger, 1993) and diagnostic ser vices such as x-ray (Skolnick, 1992). Issues arise regarding the best kind of facility or location of care for the patient who is not or is no longer acutely ill but is still infectious and requires on-going medication. Some patients are able to manage the appropriate precautions to avoid transmission to family members and others. Other patients, by virtue of their medical condition or lifestyle, arc not able to manage on their own and require a supportive environment which may include personal care assistance (Tones etal., 1990). Such services are sometimes available in outreach facilities including shelters or nursing facili ties. CDC recommendations have included establishment of special housing-treatment centers for the homeless with TB (CDC, 1992c). WHERE WE ARE GOING RESEARCH AGENDA As indicated above, the nation has a shortage of appropriate isolation facilities. In some facilities, where they exist, their mechanical systems have not been properly maintained or bal anced so that their effectiveness is limited. Consideration should be given to the development of specific planning and design guidelines, including but not limited to:

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H ealth P lan n ing Developing methodologies to calculate the number of inpatient acute and intensive care infectious isola tion rooms for a given service population. Developing methodologies to identify the type and number of hospital-based ancillary services needed to support that population including diagnostic and treatment facilities such as lab, x-ray, surgery, etc. Developing methodologies to identify alternative care delivery sites such as schools, shelters, residential treatment centers, etc. and their capacity based on the needs of the service population.

D esign a n d C o n stru ctio n Inpatient F acilities Identifying the criteria and parameters for determin ing the feasibility of renovation in existing construc tion to provide appropriate isolation capacityboth for acute and intensive care including: 1. Staffing. 2. Construction cost. 3. Construction duration* 4. Disruption to other ongoing facility operations. 5. Access to other essential support and services. Developing specific programming guidelines for iso lation facilities including the room itself, the ante room and associated bathing and toileting facilities. Identifying the specific furniture, furnishings and equipment elements required in an isolation room. Confirming the necessity of providing an anteroom: 1. As an airlock. 2. As a work and storage area in which to practice infection control measures, etc. Developing specific construction standards for doors, windows and seals based on the results of the panel investigating ventilation design.

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* Identifying specific design elements to be inc luded in the anteroom, e.g., interlocks on the doors to prevent accidental airflow between patient room and corridor. Identifying specific design elements to be included in the patientnxmi itself to accommodate ultraviolet (UV) light installations and/or high efficiency particle air (HEPA) filtrationshould their efficacy be confirmed. Identifying the appropriate design to accommodate access to and from booths for use by patients required to perform sputum induction, etc. Identifying the different needs, if any, of the short term versus long-term patient

D esign a n d C o n stru ctio n O u tp atien t andfor D iagnos tic a n d T reatm en t Facilities The above suggested areas of investigation centered on a hospital or medical centers inpatient nursing units. In addition, consider ation should be given to identifying the extent of isolation facili ties needed in other settings such as residential TB treatment facilities (Brudney and Dobkiu, 1991) and various diagnostic and treatment services. * The emergency department * Intensive care units * HTV clinics and related services such as: 1. Pentamidine administration clinics. 2. Outpatient intravenous treatment areas (Abrutyn, 1992). Specifically, within the emergency department, the triage and intake functions should be addressed in terms of the facilities required to accommodate the interaction required between patient and health care worker to determine the patient's potential for active TB. Given Joint Commission on Accreditation of Health care Organizations (JCAHO) requirements that the patient's first encounter is with triage staff, the physical setting of this interac tion needs to be examined in light of protection of the staff as well as encouraging patient safety, confidence and comfort

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Additional diagnostic and treatment service areas which should be addressed include: * * * * * * * Outpatient surgery and recovery. Clinic or ambulatory care center. Endoscopy suite or other components of a short procedure or minor surgery suite. 23-hour stay unit for pie- or post-procedural care or monitoring. Respiratory therapy. Dental operatory and clinic. X-ray.

In addition to the specific treatment spaces, waiting areas (Nolan, 1992), toileting facilities and possibly food service should be designed or planned to allow use by infectious patients or those suspected of being infectious. No standanis other than procedural protocols, generally exist for facilities such as these to deal with infectious patients. With the pressure to decrease inpatient utilization and attendant costs, it seems that pressure to develop such facilities will grow. There are also issues of containment which need to be addressed in areas such as the morgue and autopsy suite (Abrutyn, 1992). The lab itselfmay need to include P-3 containment facilities (Culliton, 1992). P s y c h o so c ia l a n d E thical is s u e s The accepted means of preventing airborne transmission rely on physical barriers, which by their very nature reduce contact between health care worker and patient. This runs counter to an increasing trend to make the health care setting and interactions more humane. For those patients whose admission is not voluntary, the issues of confinement and separation can be even more severe. Especially for those whose condition requires long lengths of stay, special consideration needs to be given to their psychosocial needs. In both acute care and intensive care settings, the possibil ity of isolation psychosis must be considered. Additional means

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of providing diversion and stimulation must be included, such as TV, interactive computers, etc. An additional area of investiga tion should be the identification of minimum levels of recreational facilities, etc. and means of allowing interaction with family members and friends without risk to either visitor or patient A lternative S ite s Consideration should be given to use of other facility types as alternatives to hospital-based care. Even though it was stated earlier that single-disease facilities are not recommended, in certain urban or metropolitan areas existing building stock may not be able to accommodate the growing need for appropriate facilitiesespecially in areas with high percentages of homeless persons who may be subjec t to invol untary confinement (Brudney and Dobkin, 1991). Consideration may also be given to regionalization of care for TB patients at risk for MDR TB (BeckSague et al., 1991). In such circumstances, criteria should be developed for the adaptation of other building types including: Schools. Psychiatric centers. Unused military installations. Criteria should include: Access to the facility from the community. Staffing availability and cost. Access to diagnostic and treatment services. Whatever national or other jurisdictional health planning mecha nisms may come out of the Clinton administrations reform program, GDC at a minimum should promulgate the results of the health planning analyses indicated above. In this same context, the Health Care Financing Administration (HCFA) must address financing of renovations and/or new construction to meet the needs of additional isolation facilities. When specific facility design and construction standards are developed, they should be promulgated by whatever entity will be
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responsible for publishing future editions of the Guidelines document. Depending upon the timing of this materia]9s produc tion, an addendum should be considered instead of waiting for a more comprehensive update. Because of the overlap, in txtfny cases, of patient populations, those groups participating in re search, public education, etc. programs on AIDS should partici pate in related TB programs. Specific educational programs should be sponsored by interested and committed industry groups such as the following: American Institute of Architects American Hospital Association Joint Commission on the Accreditation of Healthcare Organizations American Correctional Association Research participants should include the following: American Council of Schools of Architecture Research Council American Hospital Association American Institute of Architects American National Standards Institute American Public Health Association American Society of Heating, Refrigerating and Air Conditioning Engineers American Society of Hospital Engineers of the AHA Centers for Disease Control and Prevention Department of Defense Department of Health and Human Services Department of Housing and Urban Development Department of Veterans Affairs National Fire Protection Association National Institute of Building Sciences National Institutes of Health National Institute for Occupational Safety and Health (NIOSH)

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Evaluation should be performed by CDC and JCAHO, with specific emphasis on health care institutions. Local public health entities with assistance from CDC and NIOSH should evaluate other settings of care and risk such as schools, shelters, etc. HOW WE GET THEREIMPLEMENTATION The areas of proposed research should be allocated to specific groups based on expertise and ability to accomplish the research task in appropriate time frames. If possible, a consensusbuilding model should be used. Based on personal knowledge, the writer recommends an approach similar to that taken in the preparation of the Guidelines , It should be noted that tta inclusion of certain elements is dependent upon the research activities coming under the jurisdic tion of other panels. For example, the use of UV lights and HEPA fi Itration as devices in patient rooms is predicated on confirmation of their efficacy and practicality of use. The use of booths for containment of contamination generated during sputum production, aerosol pentamidine administration and bronchoscopy is predicated on outcomes by the source control panel and possibly the aerosol characterization panel. Therefore, it is recommended that an overall map or critical path be developed of the recommended tasks identi fied by each panel and that they be sequenced as needed

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REFERENCES Abnityn E. Multi dnigresistant nosocomial TB: newest facet of the HIV epidemic (Editorial). Hosp Pract 1992; Sep 30: 16. The American Institute of Architects Committee on Architecture for Health. Guidelines foi construction and equipment of hospital and medical facilities. Washington: The Ameri can Institute of Architects Press, 1993: Beck-Sague C, Dooley SW, Hutton MD, et al. Hospital outbreak of multi drug-resistant M yco b acteriu m tuberculosis infections: factors in transmission to staff and HIVinfected patients. JAMA 1991; 268: 1286. Berkow R, Fletcher AJ. eds. The Merck Manual. 15th ed. Rahway, NJ: Merck & Co. 1987: 114,120. Bloom BR, Murray CJL. Tuberculosis: commentary on a reemergent killer, Science 1992: 257: Aug; 1055-61. Brudney K, Dobkin, J. Resurgent tuberculosis in New York City: Human immunodeficiency virus, homelessness, and the decline of tuberculosis control programs. Am Rev Respir Dis 1991; 144: 749. Centers for Disease Control. Guidelines for preventing the transmis sion of tuberculosis in health-care settings, with special focus on HIV-related issues. MMWR 1990, 39:1-27. Centers for Disease Control. Meeting the challenge of multidrugresistant tuberculosis: summary of a conference. MMWR 1992a; 41: 49-57. Centers for DiseaseControl. National action plan to combat multidrugresistant tuberculosis. MMWR 1992b; 41: 1-48. Centers for Disease Control. Nosocomial transmission of multidrug-resistant tuberculosis among HIV-infectcd personsFlorida and New York, 1988-1991. MMWR 1991; 40:585-587. Centers for Disease Control. Prevention and control of tubercu losis in US communities with at-risk minority population: recommendations of the Advisory Council for the Elimi nation of Tuberculosis. MMWR 1992c; 41: 10.

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Centers t o Disease Control Transmission of multidnig resistant tuberculosis among immunocompromised persons in a coirectiooal systemNew Yak, 1991. MMWR 1992d; 41: 509. Culliton, BJ. Drug-resistant TB may bring epidemic. Nature 1992; 356; Apr 9: 473. Dubos R, Dubos J. The while plague: tuberculosis, man, and society. New Brunswick, NJ: Rutgers Univmity Press, 1992; 177-81. Glaser JB, Greifinger RB. Correctional health care: a public health opportunity. Ann Int Med 1993; 118: 143. Greifinger RB, Tuberculosis behind bars. In: United Hospital Fund of New York- The tuberculosis revival: Individual rights and societal obligations in a lime of AIDS. New York: United Hospital Fund of New York, 1992: 60. Iseman MD. A leap of faith: what can we do to curtail intrainstitutional transmission of tuberculosis? Ann Int Med 1992; 117: 251-2. Lutwick SM, Abter EIM, Chapnick EK, Moussa Z, Lutwick LL Tuberculosis in patients infected with human immunode ficiency virus: A problem-solving approach. Am J Inf Com 1992; 20: 157, NardellEA. Dodging droplet nuclei: reducing the probability of nosocomial tuberculosis transmission in the AIDS era. Am Rev Respir Dis 1990; 142: 501. Neill HM. Isolation-room ventilation critical to control disease. Health Facilities Management 1992; Sep: 30-8 Nolan CM. Human immunodeficiency syndrome-associated tuberculosis: a review with an emphasis on infection control issues. Am J Inf Con 1992; 20: 33. Pearson ML, Jereb JA, Frieden TR, et al. Nosocomial transmis sion of multi drug-resistant Mycobacterium tuberculosis: a risk to patients and health care workers. Ann Int Med 1992; 117: 193. Rothman DJ. Recommendations on the facilities needed to care for patients with tuberculosis. In: United Hospital Fund of New York. The tuberculosis revival: Individual rights and societal obligations in a time of AIDS. New York: United Hospital Fund of New York, 1992: 46-46.

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Rothman SM. The sanatorium experience: Myths and realities. In: United Hospital Fund of New York. The tuberculosis revival: Individual rights and societal obligations in a tim eof AIDS. New York: United Hospital Fund of New York, 1992: 71,73. Skolnick, AA. Correction facility TB rates soar; some jails bring back chest roentgengrams. JAMA 1992; 268: 3176. Stead, WW. Understanding tuberculosis today: a handbook for patients. 8th ed. Milwaukee: Central Press, Inc., 1992: 22. Technical Panel on Infections Within Hospitals. Tuberculosis control in hospitals. Chicago: American Hospital Asso ciation, 1992: 1-1L Torres RA, Sridhar M, Altholz J, Bricknet PW. Human immuno deficiency virus infection among homeless men in a New York City shelter Arch Intern Med 1990; 150: 2035.

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VENTILATION DESIGNS

Prepared by:

Richard D. Hermans, B.M.E., P.E. General Manager, Facilities Operations and Maintenance Saint Paul Public Schools Saint Paul, MN Andrew J. Streifel, M.P.H. Hospital Environmentalist Department of Environmental Health and Safety School of Public Health University of Minnesota Minneapolis, MN

HISTORY
On October 22,1947, rules required under Title 42 Chapter 1 Public Health Service, Federal Security Agency, Part 53 Grants for Survey, Planning and Construction of Hospitals were pub lished in the Federal Register. In this rule, specific requirements for the Ventilation of General Hospitals, Mental and Psychiatric Hospitals, and Tuberculosis Hospitals were described. Among these were the following: Rooms which do not have outside windows and which are used by hospital person nel, such as Utility rooms, Toilets, Bed pan rooms, and Baths, and Sterilizer rooms, shall be provided with forced or suitable ventilation to change the air at least once every six minutes.
Ventilation.

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Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. StreifeL MPH Kitchens, morgues and laundries which are lo cated inside the hospital building shall be venti lated by exhaust systems which will discharge the air above the main roof or 50'-0" from any win dow. The ventilation of these spaces shall comply with the State or Local Codes but if no code governs, the air in the work spaces shall be exhausted at least once every six minutes with the greater part of (he air being taken from the flat work ironer and ranges. Rooms used for the storage of inflammable material shall be ventilated to the outside air with intake and discharge ducts. The operating and delivery rooms shall he pro vided with a supply ventilating system with heat ers and humidifiers which will change the air at least eight times per hour by supplying fresh filtered air humidified to prevent static. No recirculation will be permitted. The air shall be removed from these rooms by forced system of exhaust. The sterilizing rooms adjoining these rooms shall be furnished with an exhaust ventilating system. The significance of this rule was considerable in that compliance was required in order to obtain Federal Grant money to build these health care facilities. At least one state department of health continues to use some of the language in this rule today. Notice that the interior rooms of these buildings were required to have 10 air changes per hour (ACH) and that the operating rooms only eight ACH of outside air. The beginnings of pressure relation ships were also spelled out regarding the OR and sterilizer rooms. With this rule, there began a systematic attempt to standardize the performance of health care facility ventilation systems across the country. The idea of infectious disease passing through the air from one person to one or more other people did not begin in 1947.

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In his paper entitled Historical Background, Dr. Richard L. Riley reported on the history of airborne contagion for a confer ence on that topic sponsored by the New York Acadcmy of Sciences (Riley, 1980). A quick synopsis of the history as described by Riley follows: 1862 Pasteur publi shed Memoir on the Organized Corpusc les that Exist in the Atmosphere. * 1876 John Tyndall quote: I have spoken of the floating dust of the air, of the means of rendering it visible (the Tyndall beam), and o f the perfect immunity from putrefaction which accompanies the contact of germless infu sions and moteless air. * 1910 Charles V. Chapin quote: Bacteriology teaches that former ideas in regard to the manner in which diseases may be airborne are entirely erroneous; that most diseases are not likely to be dust-bome, and that they are sprayborne, only for 2 or 3 feet, a phenomenon which after all resembles contact infection more than it does aerial infection as ordinarily understood. * 1931 William F. Wells develops the Wells centrifuge for the examination of bacteria in the air. 1934 Wells publishes On Airborne Infection. Study II: Droplets and Droplet Nuclei.* 1935 Wells and G.M,Fair publish work on the effect o f UV radiation on sterilizing air. 1941 Robertson et al. publish work on use of aerosol glycols to sterilize air.

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Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. Slreifel, MPH
1957 & 1962 R.L.Riley et al. demonstrate spread of TB by air in a Baltimore Veterans Hospital. 1968 Schulman demonstrates natural aiibome transmission of influenza in mice. 1970 A single small pox patient in a West German hospital infects 19 others whom he had never seen. 1978 E.C.Riley reports on a measle epidemic in an elementary school where the ventilation system is implicated.

Commenting on the development of the technique of air disinfec tion Riley closes his 1980 historical perspective with: Failure of cooperation between architects, engi neers, microbiologists and the people developing the technique of air disinfection has held back progress. The medical profession remains con fused and, by and large, has not given its blessing to air disinfection in hospitals." Indeed* it seems as if the engineering community and the health care community has with rare exceptions worked independently not only on disinfection of air but also on all other aspects of its conditioning and delivery. Two of the more notable exceptions are The Departmentof Health and Human Services (DHHS), (including all of its ancestors), and the American Society o f Heating, Refrigerating, and Air Conditioning Engineers, Inc (ASHRAE). DHHS, which has had an intimate involvement since 1947, today hasenlisted the services of the American Institute of Architects to continue the evolution and publishing of guidelines for health care facility construction. ASHRAE continues to edit and publish its own design guide in the form of a chapter of the popular ASHRAE handbook scries. These handbooks are enutledFundamentals, Refrigeration, HVAC Sysytems andEquipment, andApplications. Chapter 7 of the 2992 Applications Handbook contains the most recent health facilities i in

Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. Streifel, MPH
design guidelines. This chapter is presently under revisions by the Healthcare Facilities Subcommittee of Technical Committee 9.8 Large Building Air Conditioning Applications and is to be published in the 1995Applications Handbook,. The history o f this chaptcr shows the evolution of the industry and of some of the politics which shape that evolution.
A S H R A E A N D H E A L T H C A R E F A C IL IT Y D E S fG N G U ID E U N E S

In the 1959 ASHRAE Guide Chapter 8 was entitled Air Condi tioning in the Prevention and Treatment of Disease. The opening paragraphs de sen bed the e ffects of knowledge gai ned from Worl d War n regarding the importance of the control o f airborne infec tion. It also described the benefits of air conditioning in aiding the convalescence of patients. Another interesting topic io those opening remarks was the unique air conditioning problems in civil defense shelters, a topic which later moved into a separate section of the Guide book. The text describes the effects of a surface or subsurface blast of about 20 kiiotons. Given the politics of the time it is little wonder how such a topic could find its way into a discussion about health care facilities. Other topics in the 1959 Guide Chapter 8 included; Sanitary Ventilation, Control of Airborne Infection, Value of Air Cooling under Tropical Conditions, Treatment of Disease , Operating Rooms (including a subheading on leducingexplosion hazard), Nurser ies for Premature Infants, Fever Therapy, Cold Therapy, Allergic Disorders, Oxygen Therapy, and General Hospital Air Conditioning. The 1962 Guide and Data Book contained a Chapter 28 entitled Hospital Air Conditioning. Topics included: The Infection Problem, Air Quality, Air Cleaning, Air Movement, Zoning, Air Conditioning Sys tems, Design Criteria.

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Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. Streifel, MPH
This year also published Tables on AirbomeBacterial Counts and filter efficiencies for removing biological particulates. The 1964 chapter was renumbered to 29 and renamed to simply Hospitals but otherwise the text remained virtually unchanged. At this time the editing of the chapter was indicated to be assigned to Technical Committee TC 6.2 Large Building Air Condition ing, In 1966 and 1967 the first topic title (The Infection Problem) was dropped but otherwise there were no textual changes. The 1968 chapter, now numbered 14, dropped the table on fitter efficiencies and replaced it with text describing NBS dust spu( testing, protection of filters during construction, and some appli cations of various filters. The Air Movement section was ex panded this year introducing the concept of ceiling supplies and floor returns in clean areas. In addition, a new figure and accompanying text introduced an important issue which will appear in our recommendations. The text reads, The opening of a door or closure between two such areas instantaneously reduces any existing pressure between them to such a degree as to nullify the effectiveness of the pressure (ASHRAE, 1968). Figure 1 shows the air velocity vectors in an elevation of an open door. The 1968 Guide andData Book also introduced the now familiar Table 3 with the following text Table 3 gives the recommended minimum ventilation rates for the various areas of the hospital. The table has the format used to this day showing pressure relationships, minimum outside air changes, minimum total air changes, air exhausted and air recirculated with the room allow ances for various spaces. The first such Guide Book table has some changes from air changed rates recommended in the previ ous year's guidebook. A comparison of the air change rate values over the years is in the Tables section o f this paper. Between 1968 and 1971 the chapter underwent significant change. By 1971 it was numbered Chapter 15 and entitled Hospitals and Related Health Facilities. The first major title in the chapter

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Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. Streifel, MPH
ys Airflow into Operating Room 356 cfrn f t ' Airflow out of Operating Room 203 cfm

/ \

Sampler Locations

>s 0 O o a
-C

g>

Velocity Magnitude (FPM) and Direction Velocity Distribution through O p e ra tin g Room D o o rw a y {Room N o t in U se)
F ig u re 1

became Air Conditioning in the Prevention and Treatment of Disease. This was a return to the title of the entire 1959 chapter. In this section was a well-documented and scholarly description of the effects of humidity and temperature on respiration and body heat loss. Figures were added to show, among other things, heat and water exchange during respiration. The topic of Application

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of Air Conditioning to Health Facilities reintroduced The Infec tion Problem which had been previously eliminated. The primary contagion discussed under this topic was Staphylococcus aureus but many o f the basic principles for infection control described then are still relevant today for other infectious agents. The remaining two main topics were Air Conditioning Systems and Design Criteria, the latter then becoming the permanent home to Table 3 on air change rates. The 1974 edition of the chapter appeared in the Applications Handbook and began a pattern of occurring every 4 or 5 years. It became Chapter 7 and was entitled simply "Health Facilities a tide and number which has with one exception in 1987 remained the same to this day. This year also marked the reassignment of ihc chapter editing to TC 9,8 Large Building Air Conditioning Applications a shift foretold by the previous editions topic on application of air conditioning to heaJth facilities. The 1978 Applications Chapter 7 was the product of some severe editing which reduced the length from 14 pages to 10 and the references from 42 to 10. For the first time and forever since, one of the references was the US Dept.of HEW 1974 Minimum Requirements of Construction & Equipment for Hospital and Medical Facilities, now more commonly referred to as the AIA Guidelines. In this year the figures on respiration were removed along with most of the text surrounding them. Table 1 which had been titled Airborne Bacterial Counts Found in Hospital Envi ronments was now replaced with a new Table 1 on the recom mended minimum filter efficiencies and their applications which, with some modification, had appeared in previous editions of the chapter as text, and then was dropped. Beginning with this year, Table 3 divided the operating room air change rates into rccirculating and all-outside air values. There were also several signifi cant reductions in the amount of outside air recommended in spaces such as recovery, delivery, patient rooms, intensive care, isolation, anterooms, X-ray, laboratories, autopsy, and especially food preparation which had been previously listed at twenty air changes of outside air. These changes were undoubtedly due to

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major energy conservation efforts occurring in the industry at that time. A new major topic was added to the end o f the chapter entitled Energy Conservation. The 1982 chapter marked the beginning of the subdivision o f the text into parts. This year had two parts labeled Hospitals and Nursing Homes and although the hospital section had most of the text, the section onnursing homes repeated smaller versions of the tables on air change rates and filter efficiencies. The number of references dropped to nine. The 1987 chapter, temporarily numbered 23, marked the end of the subheading labeled The Infection Problem" in favor of a more upbeat Infection Sources and Control Measures. The text was more useful and specifically mentioned tuberculosis, varicella, rubella, and introduced Jegionella. The first mention of bone marrow transplant rooms requiring special filtration was mentioned. Ultraviolet sterilizing lamps went from being not recommended in the previous edition to not being mentioned at all. The topic of Design Criteria was divided into Design Criteria for Principal Areas of an Acute General Hospital and "Specific Design Criteria by Depart ment There were no changes to the air change rates in Table 3, but several new spaces were added including an X-ray treatment room and several different variations of laboratory. A new major topic called Continuity of Service and Energy Concepts was added and several subtopics like Zoning and Energy were grouped under this heading. A third major part to the chapter was added entitled Outpatient Surgical Facilities This part was added due to the demand for the construction of these facilities. The text under this part mostly referred back to the part on Hospitals. The numbers on the references disappeared and the number o f references increased to 14. The current (1992) edition of the chapter, once again listed as Chapter 7, contains new data about the role of air conditioning in special clinical treatment spaces. For example, in Table 1, a new filter has been added with 99.97 percent efficiency to be used in orthopedic surgery, bone marrow transplant, and organ transplant

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Ventilation Designs Richard D. Hermans* BME, P.E and Andrew J. Streifel, MPH
operating room applications. A new section in infection sources states that Aspergillus species can cause an untreatable and often fatal disease. The topic title Design Criteria for Principal Areas of an Acute General Hospital was dropped but most of the text remains the same as 1987. This edition* like the previous, makes reference in the text to DHHS pressure relationships and air change rates in health care spaces by saying that it is not intended for the two guidelines to agree completely. The guidelines also state that, in those few cases where ASHRAE Standard 62-1989 requires higher outside air quantities, Standard 62 should be followed. Reference is made to NFPA90A, 92A, and 101. Table 3 added a recommendation for Delivery rooms using 100 per cent outside air and a new line for Labor, Delivery, Recovery and Postpartum (LDRP) rooms. The typical patient room total venti lation was changed from 2 ACH to 4 ACH. Another Standard referred to for the first time is the Safety Code for Mechanical Refrigeration (52-1989). Table 5, the pressure relationships and air change rates for nursing homes, is dropped in this edition. The current chapter contains several ideas that date back to as far as the 1962 chapter and have survived the repeated edits of various TCs over those years. Table 2 and Figure 1 date from 1962 as well as Specific Design Criteria regarding Nurseries, Radiology, Labo ratories, Pathology, Autopsy, and Pharmacy. In some ways paralleling the work of ASHRAE, the DHHS has developed, first General Standards in I947t then Minimum Re quirementsin 1973 and finally Guidelinesfor Construction in 1984. These documents, like the original Federal Register publication, containe information which pertains to all aspects of health care design including architecture and equipment as well as engineering. The latest edition of the Guidelines(1992) has just been released and for the remainder of this paper it will be referred to as AIA. Although these two guidelines have been available since 1947, designers historically have had only to adhere to what a local building code and State Department of Health rule required by law.

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Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. Streifel, MPH
Ventilation designs in hospitals therefore, followed original con struction specifications and ongoing maintenance according to the period of construction and/or renovation. The quality o f the design often was contingent on the funding source for construc tion. Early construction used designs which included neutral air pressure relationships for isolation rooms. Subsequent design guidelines were explicit with respect to pressure controls and filtration requirements in isolation rooms construction from about 1962 on. The ventilation design before that time depended upon the hospital planning awareness towards the control of infectious disease. Such efforts to cohort and isolate patients have been a clinical practice for years extending back to the days of Florence Nightingale. Historical efforts to contain patients with infectious disease have occurred in the time of increasing sophistication in ventilation systems. The plumbing codes providing for bathroom exhaust were probably the initiation o f ventilation control in patient rooms. The engineering premise to supply air for makeup to the exhaust system then initiated the need to bring in outside air. Because of the variation in designs over the history o f health care facility construction the importance of understanding the current concepts for airborne spread of infectious disease and the role of ventilation in the control of that spread is important.
E X IS T IN G D E S IG N S N E W B U IL D IN G S

V e n tila tio n S y s te m s

General Ventilation In many ways, the modem hospital has many of the same design needs of any typical air conditioned space. Air is introduced for the dual purpose of absorbing heat within the space and resupply ing oxygen. Air is removed from the space with the absorbed heat and carbon dioxide generated by occupants. There are a number of techniques employed to accomplish these tasks, most o f which are applicable to the hospital. For the purposes of this section, we will direct our attention to the design applications which pertain to the movement of air within spaces. Later on we will discuss

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Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. Streifel, MPH
!
i

airflow rates, airflow distribution, intake and exhaust issues, outside air rates and general maintenance concerns.

Patient Rooms
Most modem hospital construction utilizes ccntral air handling systems with ducted supply and return air to each room. These rooms generally are provided with individual temperature con trols which operate some type of heating or cooling modulation for that room. The distribution system may be single duct, constant volume with reheat; single duct, variable volume, with or without reheat; dual duct with individual room mixing boxes; or single duct primary air to individual fan-powered boxes. Air can be distributed to the room through diffusers set in the ceiling or a sidewall. Air removed from the room may be taken up by return grills set in the ceiling or sidewall. Often special purpose rooms wil \ use low sidewall return systems. If the quantity of air supplied to the room is low, all of the air may be removed through the patient toilet exhaust. This has the benefit of a low first cost but does not allow for upgrading the room to a more ventilation intensive specialized purpose in the future. When air is purpose fully delivered at a low volume, such as the minimum AIA guideline of two ACH, the excess heat present in the room can be removed through a water based system such as a valance or radiant panel. Such systems can become difficult to maintain and are prone to condense moisture if the chillcd water temperature is below the dew point of the room air. In this event the panel or valance fin tube is more of a liability than a benefit. Systems which have fallen out of favor include through-the-wall unit ventilators; all-air induction ventilators; two-pipe and four-pipe fan coils; and window air conditioners. Some states discourage or ban altogether the use of variable air volume systems.

! |

| | I

Isolation Rooms
j i ] As a special case of the general patient room, the isolation room receives particular attention during the design of the modem health care facility. The current situation in hospital isolation rooms has been away fromcohortingpersonswithsimilardisea.ses. Isolation rooms have been often moved to a specific patient care

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Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. Streifel, MPH
service or are further isolated in some remote area of respective patient care units. The room configuration usually includes an attached complete toilet and shower or bath facility the door of which opens into the patient room. Some rooms are also equipped with an ante-room or airlock through which attendant personnel must proceed. Regardless of the concept for constructing the isolation room the importance of having a room with mechanical ventilation is primary. Because of this the design engineer usually provides air in one of a number of ways depending on the guidelines followed. If no guidelines were followed then the need for comfort control of the temperature and humidity are the primary consideration. The ventilation to the patient room most often supplies air from a diffuser in the ceiling or wall. Exhaust ventilation removes air from the room most often from the ceiling in both the toilet and the patient room. Some special purpose rooms use low sidewall exhaust grills. This exhaust air is generally moved directly to the outside of the building and not allowed to be recirculated. The ante^room ventilation is varied with the potential for no ventilation, supply only, exhaust only, or both supply and exhaust. Both A1A and ASHRAE describe the distinction between infeclious and protective isolation ventilation. Both guidelines recommend a minimum o f six ACH of total air volume in the patient room. In practice, the volume of air supplied is more often dictated by cooling/heating requirements for those systems that are all-air. In larger institutions, the infection control practioner may set larger air volumes for specific infection control reasons such as fungal spore control- The isolation rooms generally are constant volume with reheat to ensure that the specified pressure relationships are maintained- The design may call for a sensing device to control the volume of the air entering the room to favor the exhaust over the supply. Exhaust air is usually removed through grills rather than diffusers partly because of the cost but more so because grills are less likely to clog with debris and are easier to clean. The lack of efforts to keep grills clean often results in the oversupply of air to the room creating an effect opposite to that of containing infectious disease.

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Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. StreireU MPH

Radiology
Modem radiology departments arc areas of frequent change in the type and quantity of equipment used and the resulting impact on the building systems they require. All too often, it is only after new equipment is installed and running that the inadequacy of the ventilation to maintain an appropriate environment is discovered. For this reason, the ventilation in these department spaces receive more than the normal level of interest and attention. The attention, however, is generally due to comfort rather than infection control issues. That may be changing now that patients who are being transported from their rooms to the radiology department for diagnosis and treatment (D/T) are increasingly themselves at risk or place others at risk of infection. The diagnostic and treatment procedures within medical imaging and theraputic radiology are becoming o f longer duration and more invasive. Both guidelines are recognizing these changes by recommending air change rates separately for D/T and surgery. When the X-ray power equipment is located with the treatment room there generally is adequate ventilation to control heat gain* When the power equipment is in separate rooms the designer will usually follow the minimum recommended volumes in the guidelines. Air distribution in the treatment room will be similar to the patient room.

Waiting Rooms, Admittingf and the Emergency Department


In the 1962 ASHRAE Guide and DataBooka simple statement is found regarding these types of spaces: 'This area requires no unusual air treatment and should be conditioned for comfort of the occupants. This language remains in ASHRAE up to the latest edition, ALA does not address these spaces. These spaces should not be overlooked. The emergency room waiting and admitting area in which ASHRAE recommends 10 ACH and negative pressure should be considered for local ventilation. Local Ventilation Local ventilation, usually exhaust systems, have historically been used for a variety of purposes including infection control. Scav enger exhaust of respirated anesthetic gases have been common as have laboratory hoods for chemical fumes, biological research and testing, and radioisotope labeling.

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Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. Streifel, MPH

Special Procedure Rooms


Special exhaust systems used in gastroenterology and endoscopy are becoming more common. There is a growing use of local patient hoods which recirculate air through HEP A filters during medicated aerosol treatment of HIV patients. These hoods arc generally not of any standard construction and may have been designed in-house and built in the hospital shops. Because the very nalure of their use (sputum induction, bronchoscopies, or aerosolized pentamidine administration) generates large quanti ties of sputum droplet nuclei there is an inherent risk o f spreading infection. At present, the design guidelines do not address this consideration of health care ventilation. Research is needed in both the area of effective design of these patient hoods and of the general ventilation in the room where they are used.

Operating Rooms
The entire operating room in some cases is considered a local ventilation system. Depending upon the type of surgery done in the room the ventilation can vary from vaned ceiling diffusers or sidewall diffusers which ensure complete mixing of air, to highly specialized systems with over one hundred ACH through HEPA filters in a near laminar flow distribution* There is no consensus on the appropriate system for these rooms and so designs as well as opinions vary widely. What is agreed upon universally is the desire to prevent infection of the open wound. To that end most systems employ a combination of displacement and local ventilation. The locale however, is considered only the wound site and not the room at large. Nor do most designs consider how an infectious disease (airborne) might aftect the operating team. Here is an example of a potential application of the patient hood for this purpose. The patient is immobile and may already have some sort of respiratory control. A local e?thausl system which removes the respirations directly to the outside even for patients under local anesthesia could be effective.
A i r C le a n in g

General ventilation is completely dependent upon clean air from the central ventilation system. While building codes and state department of health rules still recognize open windows as an
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Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. Streifel, MPH
equivalent ventilation system in the health care facility modem design has all but eliminated the practice. Both AIA and ASHRAE are very specific in the recommendations for filter efficiencies for various applications. Recently, the guidelines have adopted the use of 99.97% (HEPA) filters in certain applications such as protective isolation and orthopedic surgery. There is some evidence that a design which includes filter efficiencies of 9095% throughout the entire hospital has a beneficial effect on the incidence of Aspergillus nosocomial infection (Streifel, 1993). The Centers for Disease Control and Prevention (CDC) has recommended that air potentially contaminated with infectious disease be HEPA filtered prior to being recirculated. In practice, this is seldom designed even though the recommendation dates from 1990. There are two reasons for this: 1) Air that is not exhausted directly outside is not identified as potentially containing infectious disease by the health care institution* Design professionals also do not make such a designation for this air. 2) Filters are not located in recirculated air streams. The accepted design for filter location place them in the supply air systems only. This means the mixture of outside air and recirculated air (called mixed air), is conditioned, and then is filtered before being distributed throughout the building. Figure 2 shows this concept of filtering supply air as opposed to recirculated air in central air handling systems. Research is needed in determining the optimal efficiency of filtration to prevent the spread of respective airborne infectious disease. Since the airborne particle size o f one infectious disease may be different from that of another, the filtration would need to be established for the worst case. However, if the worst case particle size was a virus, the efficacy of filtration would be in doubt. Also, the probability of infection by the airborne virus varies with the virus concentration in the air and the generation rate of virus in the space. In this case, outside air would be preferable to filtration as a dilution air source. Filtration may best be used for the fungi and bacteria particles ( >1.0 microns). Filtration efficiencies have been evaluated and the 90-95% effi-

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Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. Streifel, MPH
cient filters have been shown to remove > 99.9% of the > 1.0 micron viable fungal particles (Rhame, 1990).

R elie f A ir

R etu rn A ir

R ec irc u la te d A ir

Outside A ir

S u p p ly a ir

Air Filter

F ig u re 2. R e tr o f it

When one of the model code making bodies produce a new or revised building code, it is usually in response to input from the various authorities having jurisdiction around the country. An incident or a series of incidents prompt a review of the model code and new language is drafted, debated, and ultimately voted on in open meetings. Once adopted, individual states who subscribe to Ihe model code will review the language and either adopt it by reference or perhaps write an amended version. Then the new proposed state code undergoes the rulemaking process which includes public hearings. All of this takes a lot of time to implement. It is not unusual to have several years pass between the first draft of the model code and the completion of the state rulemaking process. During the entire process, buildings con tinue to be designed and constructed under the existing code. When the new code becomes law it has an effective date which pertains only to new designs which are reviewed and not to any

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previous. All existing construction is also"grandfathered. This concept is important to the issue of retrofitting existing healthcare facilities to new standards. If the authority having jurisdiction has a rule wh ic h sets the c onditions under which retrofit fal Is under the new codes and not the old, health care institutions planning a retrofit may consider this when deciding how much work to accomplish at once. This* along with each particular institution's financial status, has much to do with the condition of the physical plant in the hospital industry. Therefore, the types of retrofit which have the most impact on improving infection control and have the best chance of being implemented are those which; Are driven by the institution's clinical staff and sup ported by the administration. Are located in states with either strong state rules or a very competitive marketplace, Are driven by an identified source of an epidemic of nosocomial infections. In our case those implicating the ventilation system. Are easy enough and inexpensive enough to be ac complished by any institution in a short time. Are logical and easily understood by the average ventilation design engineer. Are backed by creditable research for their efficacy. Are endorsed by CDC and NIOSH.

It is a wonder how any retrofitting happens at all. In any discussion of what is happening in the industry today we must first describe the condition of the existing space and the new use to which the space is being modified. Since there are uncountable variables in describing the existing spaces we will choose a few examples of hypothetical patient rooms, isolation rooms, including protective isolation, and special procedure rooms. In each case we will choose the type of ventilation design with the greatest potential for a successful retrofit. The recommendations will describe those ventilation systems which for one reason or another are not good candidates for retrofit.

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Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. Streifel, MPH
Patient Rooms A patient care unit designed and built in the 50s or early 60s is served by medium pressure all-air induction units each with about 50 cfm of primary air which is 100% outside air. The induction units are either four pipe or two pipe with a summer/winter change over. There is a drip pan under the coil and no air filter. These units are typical of the period and were popular designs. The problem is the drip pan and the coil collect dirt and are often wet from cooling. They are maintenance headaches and potential sites for microbial growth. Buildings using this design frequently have low floor to floor heights and relatively high room ceiling heights. Windows arc openable and are quite tall. The toiiet room, if there is one, has an exhaust equal to the quantity of the primary air to ihe induction unit. Just about any retrofit of this system is expensive. The space available for ductwork is generally the ruling factor. If space is available, a totally new ducted low pressure air supply system is often suggested However, since the quantity of outside air delivered is adequate to satisfy the newly released A1A guideline new ductwork may not be indicated. By focusing on two primary problems 1) the age and location of the induction coils, and 2) the control of the cooling, a less expensive .solution often is suggested: removing all induction units, ducting the medium pressure primary air to new ceiling-mounted fan-powered boxes hidden above a dropped ceiling, and replacing the temperature controls to limit the temperature of the cooling to stay above the highest expected dew point temperature of the room. The fan-powered box is installed with 90-95% efficiency filters (generally a custom modification). Often in buildings o f this age new windows are suggested to help reduce the cooling and heating load and the air infiltration. Infectious Isolation Rooms A patient care unit built in the late 60s or early 70s has a central air handling unit supplying four ACH to the patient rooms. There is no isolation room on the unit and one room is to be converted. It is to be designated as an acid fast bacillus (AFB) isolation room.

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Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. Streifel, MPH
There is no anteroom. This retrofit will form two broad catego ries, architectural modifications and, ventilation modifications.

Architecture
Architecturally, the room receives a new sheet rock or plaster ceiling; either surface mounted light fixtures or recessed without air vents and sealed to the ceiling; seamless vinyl flooring; vinyl wallpaper walls; a headwall for medical gases and power-sealed to the ceiling; no plumbing fixtures in the room to provide an opening through the walls; a slow opening and fast closing door opener on the inward swinging door; a relatively loose fitting door, i.e., one which will allow a good volume of airto pass under it from the corridor into the room; and the same type of door on the toilet room which opens into the room. If the patient room is without a toilet room one should be added. The toilet room should have similar floor, ceiling, and wall finishes* The plumbing pipe openings should be sealed to the wall.

Ventilation
The return air ductwork to the room is cut and capped. The return grill to the room is either connected to a nearby isolation exhaust duct system or the room toilet exhaust. The grill is relocated to one of two places, either low along the wall between the patient bed and the outside wall, or in the ceiling somewhere between the bed and the outside wall. The supply air is rebalanced to provide at least 6 ACH, and the total exhaust from the toilet and patient room combined is increased to between 50 and 75 CFM, more than the supply needed for cooling or 6 ACH, whichever is higher. The room may or may not receive a air pressure monitor which will continuously monitor the relative pressure between the room and the corridor. This monitor will contain an alarm indicating an adverse condition. It may also have some control capability which would attempt to correct the adverse pressure by reducing the flow of supply air to the room. Obviously, if the control becomes too severe, the room comfort will suffer. Some alarm condition can be used to indicate the limit of the control functions ability to correct pressure problems.

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Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. Streifel, MPH
into service without much in the way of ventilation modification. Yet these procedures generate some of the highest levels of airborne infectious particles (Catanzaro, 1982). Little is being done to standardize these types of rooms partly due to the rapid appearance of their use and the general slowness of the guideline modifications.
B u ild in g A ir In ta k e a n d E x h a u s t

Few topics of building engineering design solicit more grisly tales o f horror than that of air intakes and exhausts. Carl W. Walter cited several examples in a 1980 publication (Walter, 1980)A state university hospital was designed with a below grade air intake plenum whose walls extended 8 feet above grade. This plenum was common to all air handlers in the hospital. After numerous infection outbreaks an investigation revealed 'that the screen behind the ground level intake louvers was choked with trash, leaves and wood chips from manure that had been spread over the unplanted courtyard. Similar debris had accumulated on the floor of the intake plenum. The air handling units had recirculation water spray air scrubbers. The water as well as the cooling coils were respectively murky and slimy. A second example, this time a Veterans Administration Hospital, experienced mixed clostridial and gram negative wound infec tions. Inspection revealed pigeons roosting in the intake plenum of the air conditioning system. Eight inches of guano and the decomposed carcasses of a half dozen birds littered the floor. The filters, laden with molding dust, had dropped out of their frames and the refrigerating coils were a confluent mass of slime and mold.* A third example isofaun iversity hospital' s c ardi ac c atheterization laboratory. Air samples showed heavy contamination of aspergillus and S. epidermidis. It was air conditioned by a domestic type window unit that projected over a trash compactor. Its filter was moldy. Its refrigeration coils and fan were slimy. Obvi ously, lack of proper maintenance played a major part in each of

1?

Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. Streifel, MPH
these examples. In most cases however, a design sensitive to the needs of clean air will prevent or minimize these sort of problems. Examples of good practice include the following designs: Exhaust fans are located at the discharge end of the distribution system with pressurized ducts run only in mechanical rooms. Outside air intakes are located at least 25-30 feet from exhaust outlets, combustion stacks, medical vacuum exhaust, plumbing vents, or any other noxious fumes, (such as trash dumpsters). Outside air louvers are placed as high as possible but at least six feet above grade or at least 3 feet above a roof. The prevailing wind and site conditions around the building are considered and may increase these minimum distances. Bird screens arc no smaller than one-quarter inch mesh. Intake plenums are adequately drained.

In certain settings, outside air may not be the best source for clean air used in dilution ventilation. Although criteria exists to deter mine the acceptability of outside air for general indoor air quality purposes (ASHRAE, 1989), specific health care facility require ments have not been published. There appears to be a gap in the literature regarding any special needs the health care community may have to pretreat outside air before it is admitted. Tradition ally, air which is recirculated is not conditioned independently from outside air. Independent conditioning processes such as filtering may be useful in locations where the outside air is particularly polluted.
A ir flo w R a te s

Among the most controversial aspects of the engineering control of airborne infection are airflow rates. Existing guidelines are specific in prescribing the relative quantities of total air movement in various

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Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. Streifel, MPH
health cane spaces and of that portion of the total air which must come from outside. Much confusion develops over these prescriptive requirements because neither AIA nor ASHRAE describe their basis or origin. As we have seen in the history, airflow rate prescriptions go back at least to 1947 when ventilation systems in all buildings including hospitals were strictly intended for human comfort Some times even that design criteria was poorly met. Today, health care space designs are constrained by forces which include liability and costs of construction as well as energy. The new or inexperienced health care ventilation engineer is met with a bewildering array of sometimes conflicting requirements, guidelines, hearsay, and preju dice which try to influence the design. Frequently, long established engineering firms with traditions of service to this industry will follow one or a very small set of design criteria, forsaking aU others in order to bring some sense to the chaos. This also serves to limit the time spent on research of alternate designs. Since the mandatory requirements for construction needed to obtain construction grants under the Hill-Burton act became merely guidelines it has been up to either the State Department of Health or the health care organization itself to establish minimum criteria for design including airflow rates. On occasion the health care organization will employ the services of the epidemiologist or orthopedic surgeon to assist the ventilation engineer in establishing criteria for air change rates. Facilities with active research in such areas as transplant surgery, orthopedic surgery, bone marrow trans plants, tuberculosis, or HIV Clinics may have requirements for specific rooms which may not be covered in the design guidelines. Medical centers of excellence are frequent across the country and many very good designs are in place which never are shared in the literature. By the same token, some gruesome designs are in place which barely serve their present function, sometimes because of poor design, but more frequently because the space was never designed for the present function it serves. It is sometimes amazing to see the number of otherwise ordinary patient rooms, which may date back to the early Hill-Burton construction designs that are pressed into service as isolation rooms, often with little or

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no modification to the ventilation system. The section on retrofit addresses some o f the ways in which these conversions are accomplished with mixed success. Table 6 lists the air change rates presently published in the AIA and ASHRAE documents. Various states have adopted, or modified these, usually upwards, and other states have published entirely separate requirements, S ome states have no requirements beyond the original Hill-Burton language of the Iale 40s or early 50s. It has largely been the influence of third party payers such as Medicare and Medicade as well as the private insurance industry which has driven health care organizations to adopt ever more stringent standards for minimizing the spread of airborne infec tious disease by ventilation systems. On the other hand, it has been the desire of limiting the rising cost of health care construction and building operation which has prevented universal acceptance of guidelines where they are not backed with the force of law. The health care facility design community is at best not unani mous and is often divided on the issue of increasing minimum airflow rates, especially in isolation rooms and operating rooms, for the purpose of minimizing the spread of infection. At even greater discord is the issue of differential pressure between spaces for the same purpose. It can be safely said that although there has been much published about the spread of infectious disease and the possible implication of the ventilation system in epidemics, little research in how ventilation systems effectively control airborne diseases within spaces is appar ent. Research is needed in this area. Such research, although obviously in need of careful input from the medical community, is best conducted from the ventilation engineering viewpoint. Air change rates, such as those listed in Table 6 are the result of many years of practical and often empirical study. Some space airflow rates listed have had more scientific research than others. Some have been handed down from revision to revision and swapped between one guideline to another, having lost in the

Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. Streifel, MPH
process the original research which was their basis. To challenge them now could be likened to closing the gate on an empty corral. To stretch the metaphor, we, like the farmer, need livestock in the barnyard in order to bexreditable.
A ir flo w D is t r ib u t io n

The primary role played by mechanical ventilation is that of maintaining a comfortable environment in the space ventilated. This is as true in health care settings as much as in other general buildings. The role of moving air in a space being used for infection control is not often used and very little understood. The most notable exception is the so-called laminar flow system for operating rooms, so-called because true laminar flow spaces, the sort used in computer chip manufacturing, require elaborate floor or wall plenums to receive the parallel airflows without restriction. Today the operating suites which contain banks of HEPA filters in the ceiling or a wall generally have more conventional return/exhaust grills. Still the concept of using air as a mechanical force to direct particles to behave in a predictable fashion has been used in several health care settings including fume hoods, scavenger exhaust, and of course operating rooms. The entire concept of local ventilation depends upon the velocity of airdirecting fumes or particles to be captured and either trapped in a filter or simply exhausted outside. Dilution ventilation has as its basic premise a dependence on complete mixing of air and contaminants. The air distribution in a room becomes at least as important as the quality and quantity of that air. Fortunately, diffusers which distribute air with the intent to provide a comfortable temperature also do a fairly good job of mixing contaminants with the clean incoming air. There are still pockets of stagnant air present in just about any diffuser layout which could create areas of static infectious particles. These stagnant areas need to be minimized in the design which is considered infection control. ASHRAE has developed a standard which evaluates the performance of room air diffusion. The standard is a method of testing temperatures and velocities at various locations in a room and from the measurements calculate

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Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. Streifel, MPH
ing an effective draft temperature. From this an Air Diffusion Performance Index (ADPI) for the room is determined (ASHRAE, 1990). This index could be used as an indication of good air diffusion for complete mixing of contaminants. This is an important aspect of dilution ventilation. Most common among the designs for distribution of air in spaces is the ceiling delivery through vaned diffusers and ceiling removal through grills. The factors which influence the ADPI are location of the supply diffusers; their size relative to the quantity of air delivered; the distance the air travels before the velocity decays to less than 50 feet per minute (commonly referred to as the throw); the total quantity and temperature of the supply air; and tne location of the return grill relative to the location of the supply. The value of the ADPI is to measure the ability of the air diffusion system to produce an acceptable thermal environment. It could be said that it may also measure the ability of the diffusion system to evenly mix airborne contaminants in the air. The contaminants mixed are those which would otherwise be suspended and not fall to the floor in still air such as droplet nuclei. Research is needed to establish the connection between the homogeneous concentra tion of infectious particles and the air diffusion systems1 ADPI.
O u t s id e A ir R a te s

One of the more confusing aspects to the guideline recommenda tions for ventilation is the reference to outside air rates. This is partly due to the fact that the numbers listed in the tables are reported in ACH for both outside air and total air volume. When the standard for acceptable indoor air quality was published, the values listed for outside air quantities were in cubic feet per minute per person (CFM/P) (ASHRAE, 1989). To add to the confusion, both guidelines referenced this standard for minimum volumes of air. Since most central air handling systems and their distribution ductwork do not generally separate the outside air from the recirculated air, it is not obvious how to comply with delivering ratios of outside air which change from room to room. Central ai r 133

Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. Streifel, MPH
handling systems provide only one ratio of outside air. This is also a valid argument against variable air volume systems which tend to favor recirculated air when total volumes are reduced. Since the ACH values listed are only minimums it becomes necessary to increase the total volume of air to each room until the correct minimum quantity of outside air present in the supply air is reached. Therefore, AHUs with higher outside air ratios may supply lower total air volumes to satisfy the minimum outside air. For example, the 1991 ASHRAE recommendation for patient rooms is 4 ACH with 2 ACH of outside air. If the typical 1000 cubic foot single patient room received 4 ACH of fifty percent outside air both minimums would be met with about 66 CFM of total air. However, if the air delivered were 30 percent outside air then in order to meet the 2 ACH the total air delivered needs to be about 110 CFM (33/0.3). Both minimums are still met but more total air is delivered if the ratio of outside air is less. In this way each space of die facility can meet the intent of the guideline with air delivered by a central air handling unit of a fixed outside air percentage. Establishing what the fixed outside percentage will be is and should remain the decision of the ventilation design engineer. In practice, the modem health care facility usually requires more than the minimum total air in order to meet the comfort requirements.
M a in te n a n c e

The previous discussion regarding outside air intakes and exhaust systems establishes the critical need to properly maintain the health care ventilation system. Although these examples are particularly dramatic the more common situation is one of gener ally good care. The typical hospital engineering department is well aware of the need to replace filters, clean air intakes and exhaust plenums, and monitor general operation of the ventilation system. It is true that the larger institutions have somewhat more flexibility to program preventive maintenance due to larger staffsizes but this is changing due to cutting of department budgets. Much good has been done by the Joint Commission for the Accreditation of
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Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. Streifel* MPH
Healthcare Organizations to lift the awareness of both maintenance and administrative staffs to the importance of maintenance planning and record keeping. Often the infection control department will work with the maintenance department to combat some problem which may have manifested in a nosocomial infection outbreak associated with the environment. On these occasions awareness of mainte nance of the ventilation system becomes apparent and if necessary greater attention to operational efficiency is required. Routine regular cleanings of patient room supply and exhaust grills are the best method of preventing air balance problems caused by clogging. Rooms with low sidewall exhaust grills are particularly susceptible to dust and lint from the floor. Operating rooms as a rule collect scrub lint in their returns. Special care is often given to humidifiers within duct systems. When any direct water injection, either by steam or cold water, is made into the air stream a potential for biological growth exists. Certain areas of the country still use evaporative cooling even in health care settings. These devices are particularly prone to harboring microbes which could grow to a point where they become entrained into the air. Main tenance procedures for these type s o f water/air mixtures general ly are repeated more frequently to minimize such growth. The availability and acceptance of computerized scheduled main tenance has allowed the modem hospital engineering staff to plan more effectively the necessary resources to accomplish the diffi cult task of maintaining today's highly technological mcchanical and electrical systems. Some institutions are moving beyond preventive maintenance into predictive maintenance which will with some accuracy prcdictfailiues to critical building systems before they happen. This allows scheduled shutdowns to make repairs or replacements without the stress of the emergency outage.

Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. Streifel, MPH
R E C O M M E N D A T IO N S S h o rt T e rm r e c o m m e n d a tio n s

We must do whatever is economically possible in the short term to bring all health care facilities up to a minimum level of protection against the spread of some airborne infectious diseases, namely tuberculosis. That minimum level should include: At least one isolation room with an anteroom in each facility which meets the minimum requirements for AFB isolation described below. A program of minimum maintenance on the mixed air dampers, the filters and coils, and the air balance in the isolation room(s). A plan which outlines the timetable to bring the entire facility up to the present guideline recommendations for air filtration, outside air volumes, and total air volumes.
r e q u ir e m e n ts f o r A F B is o la t io n

M in im u m

The minimum requirements for a completely sealed single patient room are the following: Plaster or sheet rock ceilings, either surface mounted light fixtures or fixtures without vents caulked to the ceiling. Horizontal surfaces should be cleanable with no penetrations other than sealed electrical outlets. Headwalls for medical gases sealed to the ceiling. Air supply diffusers which have an Air Diffusion Performance Index (ADPI) of 80 percent or more. Low side wall returns in the patient room between the outside wall and the patient bed. At least 12 airchanges per hour of 90 percent filtered air.1 A11airexhausted out o f the room through a fan system dedicated for isolation exhaust.

1 V ariables are a 1 in 20 chance o f in fe c tio n fo r a stay o f 30 m inutes; 6 0 qph, 210 C F M , a 1000 cubic fo o t room .

Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. Streifcl, MPH
The exhaust fan mounted on the roof or in a penthouse with a minimum of positive pressure duct. An ante room containing a sink and storage. At least 20 ACH in the ante room of exhaust going to the same isolation exhaust fan system and no supply for makeup air with both doors opening into the ante room arranged so that the swings intersect. Both doors on automatic door closers with slow open and quick close mechanism and no weatherstripping on the doors to allow air to flow through them. An electronic or pneumatic monitor to constantly measure the differential pressure of the patient room with respect to the corridor and alarm when the relationship changes.

This suite o f rooms (patient, toilet, and ante room) should be left in infectious isolation condition at all times, even when used for non-infectious patients. Emergency room facilities should pro vide rooms with the same criteria for isolating a suspect emer gency patient with an infectious disease.
M a in te n a n c e f o r a ir h a n d lin g s y s te m s

The CE>C and NIOSH should commission the American Society of Hospital Engineers (ASHE) and AS HRAE to develop and publish minimum required maintenance procedures for filter changing, as well as coil, diffuser and duct cleaning. These requirements should include maintenance of mixed air damper operation and their con trols. At least semi-annually, each air handling unit (AHU) should be stopped and its interior inspected for filter integrity. The mixed air dampers should be operated through their full range of motion, the coils should be measured for pressure drop due to dirt. When the fan is operating, the mixed air, outside air and return air temperature should be measured as a means to determine the percentage of outside air being admitted. The volume of air entering and leaving the isolation room(s) should be measured All of the above should be recorded. Routinely a smoke stick should be used to verify airflow movement in the designated ventilation controlled isolation rooms.

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Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. Streifel, MPH
L o n g T e rm O u t s id e A ir R e c o m m e n d a tio n s

Since outdoor air ts not always the best source for clean air used in dilution ventilation, pretreatment to remove particulates and gases should be installed. In new design, the outside air intakes should be above the roof. If mechanical equipment rooms arc not in penthouses then outside air shafts communicating with the roof should be provided. Exhausts for removal of infectious air should be designed for minimum effective stack heights of 35 feet. The fan should be mounted outside on the roof with a vertical dis charge of 3000 feet per minute or more.
A ir flo w R a te s

The volume of outside air to a space which contains a source or a potential source of airborne infectious disease shouldbe designed for controlling theconcentration of infectious doses present in the air. The design then becomes based on the concept of assumed risk. It can be shown that the probability of an infection in a ventilated room is dependent on the variables found in the ReedFrost equation (Riley, 1989).
C = S ( l- e ^ )

where: C = number of susceptibles S who become infected S = number of susceptibles / = number o f sources (already infected) p = pulmonary ventilation in volume per unit time t = exposure time (minutes) Q = removal rate by fresh air (CFM) q = number of doses of airborne infection added to the air per unit time by a case in the infectious state Tf the quanta (q) can be determined for each disease in each type of room or each procedure then the design parameters of the ventilation system will depend only on the level of risk allowed and the time a susceptible person spends in the room.

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Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. Streifel, MPH
Assume for the moment that a 1 in 10 chance of infection is acceptable. An isolation room with an active TB patient could be ventilated such that a person entering without a mask could stay in the room for a length of time dependent upon the ventilation rate in the room The longerthe stay the higher the risk of infection. If long stays are needed the ventilation could possibly be increased for the duration of the stay then be returned to some base line level. In a modem isolation room of about 120 square feet and 6 ACH of 95 perccnt filtered airQwould equal about lOOcfn^however^since the filter efficiency is 95%only 95 cfm can be considered clean. This assumes that the filter can stop 95% of the particles needed for infection. If the particles are virus size the filtration dilution volume would default to the volume of outside air. A quanta calculation of a tuberculosis patient in a hospital setting setq at 60qph (Riley, 1962). Solving for t: t = -Q /Ipq*ln[l-(C /S)] where: I= 1 p = 0,352 cfm C=1 S = 10

With these variables, the time (t) becomes a little less than 30 minutes. Using this logic a table can be developed listing the airflow rate along one axis, the time spent in the room along the other and the probabilities of infection for each cfm at each length of stay (Tables 1 through 5). Such a table would be specific for each infectious disease and each type of ventilation system. The ventilation system is important because of the assumed air mixing in the formula. The obvious need for research is to establish standard quanta (q) for each disease. The quanta also will vary by the ability of the susceptible to fight off the infection before symptoms occur. Therefore, the quanta will depend upon who is being threatened

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Ventilation Designs Richard D. Hermans, BME, PE and Andrew J. Streifel, MPH


with infection, e.g., immuDosuppressed patients or staff. Quanta have been estimated by calculating from epidemics the effect of the index case and the successive generations of suscepdbles who became infected. Intubation and bronchoscopy of a TB patient: 249 qph (Catanzaro, 1982), Laryngeal tuberculosis in a hospital: 60 qph (Catanzaro, 1982). Tuberculosis spread in an office building: 13 qph (NardeJl, 1987). Tuberculosis patient receiving chemotherapy: 1.25 qph (Riley, 1962). Measles in an elementary school: 93 qph (Riley EC, 1978).

Any research to establish these quanta should also recommend those values which would be used for the purpose of designing ventilation systems. The quanta so used may be higher than the actual generation rates discovered in research. Room design for infectious particle control should be studied to provide for supply diffuser types and locations along with exhaust locations which would effectively remove airborne infectious quanta. The air changc rate and airflow pattern should work in concert to control the release of patient derived infectious airborne particles. Since undiagnosed TB is a danger anywhere in the health care facility setting, minimum filtration of air everywhere in the building should be set at 90-95%. Outside air rates for every AHU should be set to provide an adequate dilution ventilation for infectious particles loo small to filter. Policy should be set for the acceptable calculated risk of infection and the maximum length of stay (unmasked) in the presence of an active TB ease. By establishing these parameters and using the concept of designing to the maximum allowed risk the ventilation engineer can design the ventilation system to the specific requirements of each institution. The minimum recommended ventilation design guidelines should not also be considered the maximum ventilation for everyone. 140

Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. Streifel, MPH
T A B L E S P R O B A B IL IT IE S O F IN F E C T IO N

T a b le 1 Q U A N T A = 1.25 T IM E I N M IN U T E S 10 0.001 0.001 0.001 0.001 0.000 0.000 0.000 0.000 0.000 0.000 0.000 T a b le 2 Q U A N T A = 13 T IM E I N M IN U T E S 10 0.015 0.010 0.008 0.006 0.005 0-004 0.004 0.003 0.003 0.003 0.003 20 0 .030 0 .020 0.015 0.012 0.010 0.009 0.008 0.007 0.00 6 0.00 6 0.005 30 0.045 0.030 0.023 0.018 0.015 0.013 0-011 0.010 0.009 0.008 0.008 40 0.059 0.040 0.030 0.024 0.020 0.017 0.015 0.014 0.012 0.011 0.010 50 0074 0.050 0.038 0.030 0.025 0.022 0.019 0.017 0.015 0.014 0.013 60 0.088 0.059 0.045 0.036 0.030 0.026 0.023 0.020 0.018 0.017 0.015 50 75 100 125 150 175 200 225 250 275 300 C FM 20 0.003 0.002 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.000 30 0.004 0.003 0.002 0.002 0.001 0.001 0.001 0.001 0.001 0.001 0.001 40 0.006 0.004 0.003 0.002 0.002 0.002 0.001 0.001 0,001 0.001 0.001 50 0.007 0.005 0.004 0.003 0.002 0.002 0.002 0.002 0.001 0001 0,001 60 0,009 0.006 0.004 0.004 0.003 0.003 0.002 0.002 0.002 0.002 0.001 50 75 100 125 150 175 200 225 250 275 300 C FM

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Ventilation Designs Richard D. Hermans, BME, P.E and Andrew J. Streifel, MPH
T a b le 3 Q U A N T A = 60 T IM E IN M IN U T E S 10 0.068 0.046 0.035 0.028 0.023 0.020 0.017 0.016 0.014 0.013 0.012 T a b le 4 Q U A N T A = 93 T IM E IN M IN U T E S 10 0.104 0.070 0.053 0-043 0.036 0.031 0.027 0.024 0.022 0.020 0 01B T a b le 5 Q U A N T A = 249 T IM E 1N M IN U T E S 10 0.254 0.177 0.136 o nt 0.093 0.080 0.071 0 063 0 057 0.052 0.048 20 0.443 0.323 0.254 0.209 0.177 0.154 0.136 0.122 0.111 0.101 0.093 30 0585 0.443 0.356 0.296 0.254 0.222 0.197 0.177 0.161 0.14S 0.136 40 0.690 0.542 0.443 0.374 0.323 0.285 0.254 0.229 0.209 0.192 0.177 142 50 0.769 0.623 0.519 0.443 0.386 0.342 0.307 0.278 0.254 0.234 0.217 60 0.828 0.690 0.585 0.505 0.443 0.395 0.356 0.323 0.296 0.274 0.254 C FM 50 75 100 125 150 175 200 225 250 275 300 20 0.97 0.136 U.14 0.084 0.070 0.061 0.053 0.047 0.043 0.039 0.036 30 0280 0.197 0.151 0.123 0.104 0.090 0.079 0.070 0.064 0.058 0.053 40 0,354 0,253 0.197 0.161 0*136 0.118 0.104 0*093 0.084 0-077 0.070 50 0.421 0,306 0.239 0*197 0.167 0.145 0.128 0.114 0.1CW 0.095 0.087 60 0.481 0,354 0.280 0.231 0-197 0.171 0.151 0.136 0.123 0.113 0.104 CFM 50 75 100 125 150 175 200 225 250 275 300 20 0.132 0.0 90 0*068 0*055 0.046 0.040 0.035 0.031 0.028 0.025 0.023 30 0.191 0.132 0.100 0.081 0.068 0.059 0.052 0.046 0.041 0.038 0.035 40 0.246 0.172 0.132 0.107 0.090 0.078 0.068 0.061 0.055 0 .0 5 0 0.046 50 0-297 0.210 0.162 0.132 0.111 0.096 0.S4 0.075 0.068 0.062 0.057 60 0.345 0.246 0.191 0.156 0.132 0*114 0.100 0.090 0.081 0.074 0.068 50 75 100 125 150 175 200 225 250 275 300 CFM

Table 6
Ventilation Designs Richard D, Hermans, BME, P .E and Andrew J. Streifel, MPH ASHRAE AIR CHANGE RATES OVER THE YEARS

1959 OR 100% O A R EC IR C D E L IV E R Y 100% O A R EC IR C RECOVERY N U R SE R Y TRAMA RM A N E S T H STO P A T IE N T R M T O IL E T R M IN T E N . C A R E IS O L A T IO N ANTERO OM LD R P 2 1.5 8-12 8-12

1962 15

1964 15

1966 15

(T O T A L A IR /O U T S ID E A IR ) 1974 1971 1973 1968 15 25/5 25/5 25/5 25/5

1982 15 25/5

1987 15 25/5

1991 15 25/5 \5

15 4 12 2 1,5

15 4 12 B 2

15 25/5 4 12 8/8 4/2 6/6 15/6 15/5 25/5 8/8 4/2 10 6/6 12/12 6/6 25/5 15/6 15/5 25/5 8/8 4/2 10 6/6 12/12 6/6 25/5 15/6 15/5 25/5 8 2/2 10 6/2 12/12 6/6 12/5 6/2 12/5 12/5 8 2/2 10 6/2 6/2 10/2 12/5 6/2 12/5 12/5 8 2/2 10 6/2 6/2 10/2 12/5 6/2 12/5 12/5 8 4/2 10 6/2 6/2 10/2

12/5 6/2 12/5 12/5

10 6/2 10/2 4/2

Ventilation Designs Richard D. Hermans, BME, P .E and Andrew J. Streifel, MPH

(TO TAL AIR/OUTSIDE A IR )


1959 P A T IE N T CORR R A D IO L O G Y X -R A Y SUR G ER Y X -R A Y D & T DARKROOM LABO R A TO R Y GENERAL B A C T E R IO L O G Y B IO C H E M IS T R Y CYTO LO G Y G LASSW ASH H IS T O LO G Y NUC M ED PATH O LO G Y S E R O LO G Y S T E R IL IZ A T IO N M E D IA T R A N S 4/4 4/4 4/4 4/2 4/2 10 4/2 6/2 10/2 10 10 10 6 /6 6/6 6/6 6/2 6/2 6/2 6/2 6/2 6/2 10 6/2 6/2 6/2 6/2 to 4/2 6/2 10 6/2 6/2 6/2 6/2 6/2 6/2 6 10 6 10 10 12 6 /6 15/6 6/6 15/6 6/6 L5/6 6/2 10/2 6/2 10/2 15/3 6/2 10/2 15/3 6/2 LO/2 1962 1964 1966 1968 4/4 1971 4/4 1974 4/4 1978 4/2 1982 4/2 1987 4 /2 1991 4/2

AUTOPSY 10 B O D Y H O L D (N O F R IG ) PHARMACY

10

15

15/6

15/6

15/6 10

12/2 10 4/2

12/2 10 4/2

12/2 10 4/2

12/2 4/2

(TO TA L AIR/OUTSIDE A IR )
1959 DAT EXAM M ED ROOM TREATM ENT PHYS TR PY S O IL E D H L D CLEAN H LD S E R V IC E F O O D PREP W AREW ASH * D IE T A R Y LAU N D R Y 10 10 10 20 20 20 20/20 10 2 10/10 20/20 10 2 10/10 20/20 10 2 10/10 10/2 10 2 10/2 10/2 10 2 10/2 10/2 10 2 10/2 10/2 10 2 10/2 4 4 3 4 3 12/6 4 3 12/6 4/4 12/4 12/4 12/6 4/4 32/4 12/4 6/2 4/4 12/4 12/4 4 4 4 12/6 12/6 12/6 6/2 4/2 6/2 6/2 10/2 4/2 6/2 4/2 6/2 6/2 10/2 4/2 6/2 4/2 6/2 6/2 10/2 4/2 6/2 4/2 6/2 10/2 4/2 1962 1964 1966 1968 1971 1974 1978 1982 1987 1991

Ventilation Designs Richard D. Hermans, BME, P .E and Andrew J . Strcifel, MPH

S O IL E D U N C L E A N L IN TRASH C HUTE BEDPAN RM BATHROOM JA N IT O R S C L O

8 8

8 8

8 S 10/2

10 2/2 10/2 10 10

10 2/2 10/2 10 10 10

10 2/2 10 10 10 10

10 2 10 10 to 10

10 2 10 10 10 10

10 2 10 10 10 10

10 2 10 10

10

10

Ventilation Designs Richard D. Hermans, BME, P.E and Andrew S. Streifel, MPH
REFERENCES

ASHRAE 1968 Guide and Data Book; Chapter 14, page 147, ASHRAE Standard 62-1989. Ventilation for Acceptable Indoor Air Quality. ASHRAE Standard 113-1990. Standard for Measuring the Air Diffusion Performance in a Room. Catanzaro A. Nosocomial tuberculosis. Am RevRespir Dis 1982; 125:559-62, N ardell E Weidh aas S, Keegan J, et al. Tuberculosi s transmissi on in a tight office building: the theoretical limits of protec tion achievable by increased ventilation. Am Rev Respir Dis 1987; 135:A33. Riley EC, Murphy G, Riley RL. Airborne spread of measles in a suburban elementary school. Am J Epidemiol 1978; 107:421-32. Riley RL, Mills CQ CTGrady F, Sultan LU* Wittestadt F, Shivpuri DN. Infectiousness of air from a tuberculosis ward ultraviolet irradiation of infected air: comparative infec tiousness of different patients. Am Rev Respir Dis 1962; 85:511-25. Riley RL. Historical perspective, Ann NY Acad Sci 1980; 353:3-9, Rhame, F.S. et a. Evaluation o f commercial filters for fungal spore removal efficiency. 3rd International Conference on Nosocomial Infecti ons, Atl anta, GA, July 31 -Aug3,1990. Riley RL, Nardell EA* State of the art: clearing the air. Am Rev Respir Dis, 1989; 139:1286-1294* Streifei AJ, Rhame FS* Hospital air filamentous fungal spore and particle counts in a specially designed hospital* Transac tions of Indoor Air 93, Helsinki* Finland. 1993 (In Press). Walter CW. Prevention and control of airborne infection in hospitals. Ann NY Acad Sci 1980; 353:312-330.

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Research Recommendations
R E S E A R C H A E R O S O L R E C O M M E N D A T IO N S F O R

C H A R A C T E R IZ A T IO N

IN T R O D U C T IO N

The development and assessment of various engineering control strategies for infectious aerosols depend on an understanding of the biological agent and the carrier particles to which they may be attached. The ability to accurately assess infectious aerosols requires an understanding of how those aerosols behave in the environment. The survivability and vulnerabilities of infectious organisms as they exist in an aerosol form need to be explored. Investigators need to characterize the physical and biological nature of the particles when originally introduced into an environ ment and when resuspended from previously settled particles. Finally, aerosol control technologies, including filtration and ultraviolet germicidal irradiation, need to be evaluated and ap plied where appropriate. These research recommendations for aerosol characterization are the result of two days of discussions by a scientific panel. The panel included scientists with backgrounds and experiences in aerosol physics, microbiology, engineering, and industrial hy giene. The panel began with discussion of Dr. Eugene Coles paper and plenaiy presentation on Aerosol Characterization. Upon concluding their discussion, the panel developed the fol lowing general recommendations: Characterize infectious aerosols as they emerge from the source. Assess physical properties such as shape, size, and aerodynamic properties. Improve existing or develop new sampling and ana lytical methods. Study the microbial ecology o f infectious agents in the environment.

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Research Recommendations
Select model pathogens for use in testing sampling methods and controls. Evaluate control technologies, individually and in combination. Evaluate the performance of nitration control. Characterize and assess resuspended aerosols.

Once these recommendations were developed, the panel at tempted to set priorities for these research needs. There was unanimous agreement that the first three items on the bullet list above were very important researchneeds. The study of microbial ecology was listed slightly lower, as highlyimportant. The consen sus opinion for the fourth and fifth items on this list was to rate them as moderately important, each of these items was rated as a very important research need by at least one of the panelists. The last two items on this list were rated moderatelyimportant^y the whole panel.
P R IM A R Y A E R O S O L C H A R A C T E R IZ A T IO N

A primary research goal identified by the committee was the characterization of infectious aerosols as they emerge from the source. To validate laboratory studies with test organisms, the carrier particles need to be matched to the real-world particles. Infectious aerosols in health care settings will include sputum and other condensed material besides the viable organism(s). The aerodynamic properties of the carrier particles will affect the settling velocity, residence time in the environment, and the capture velocity needed to remove the infectious particle from an airstreaxn. Other control strategies, such as the efficacy of ultraviolet germicidal irradiation may be affected if the organism is occluded by surrounding mucosal material. Some specific research objectives that were identified are: Characterize respiratory emissions from patients. Characterize carrier particles from environmental sources such as shower sprays, cooling towers, HV AC systems, etc.

150

Research Recommendations
Characterize aerosolized particles containing bacte ria, fungi, and viruses. Characterize aerosols generated by medical devices or invasive procedures such as bronchoscopy or laser surgery.

P H Y S IC A L P R O P E R T IE S

The size, shape, and aerodynamic properties of infectious agents in the environment should be assessed. To develop sampling and analytical methods, one needs to understand the size, shape, and viability of infectious agents. Organisms may transform them selves (size, shape, density) to survive in the hostile aerosol environment (desiccation, ultraviolet exposure, lack of nutrients, and presence of chemicals and disinfectants). Consequently, their aerodynamic properties may be different in the environment than those agents in the laboratory or those immediately after emission from the patient or source. Some specific research objectives are: Investigate aerosol size and shape transformations in the environment and in vivo, to avoid introducing sampling artifacts. Understand how organisms survive as an aerosol, providing insight for control strategies. Collaborate with microbial ecologists,

S A M P L IN G & A N A L Y S IS

Existing sampling and analytical methods for infectious agents need to be improved and new ones developed. To control exposure, evaluate controls, or identify potentially hazardous conditions, technologies for rapidly and reliably assessing the presence and quantity of infectious agents are needed. Develop methods for sampling and analysis for each category of agent, e.g., bacteria, fungi, and viruses.

151

Research Recommendations
Develop sampling techniques that include personal samplers, large volume samplers, and size fractionat ing samplers. Develop techniques to provide rapid detection* opti mally producing an instantaneous and continuous monitor. Interface air sampling methods with gene amplifica tion (PCR) and immuno-rfiemical techniques for assessing, identifying, and quantifying airborne mi croorganisms.

M IC R O B IA L E C O L O G Y

The microbial ecology of the airborne organisms should be studied. Factors that regulate growth, including organisms re sponse to drugs, disinfectants, and ultraviolet light, provide in sight into control strategy options. The ability of organisms to survive in sample collection devices may also represent a signifi cant problem. For viable sampling methods, the organisms must maintain their ability to reproduce and grow following impaction, impingement, and possible desiccation on a filter or other sam pling surface. Specific research objectives are: Explore viability of microorganisms: viability in the source, survival in aerosolization, survival in trans port (turbulence). Explore microorganisms survival in sampling. Collaborate with aerosol physicists.

M O DEL PATHO G ENS

It may be argued that most o f the research objectives identified for control of infectious agents in health care and related facilities depend on the availability and suitability of model organisms to be used in experimental protocols. The model organisms are required to test sampling devices and to assess the effectiveness of control technologies without using the pathogens themselves.

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Research Recommendations
There is a need to identify and select model pathogens for use in testing sampling methods and control technologies. Models for bacteria fungi, and viruses may be needed. Pathogens of concern that require model organisms include, but are not limited to: M . tuberculosis, Legionella>Aspergillus^ and rubella, influenza, varicella, adenoviruses, and measles. While there will be no one organism that will meet the needs of every possible experimental program, sets of candidate organisms can be identified and made available. Some specific research objectives identified to meet this need include: Establish selection criteria for surrogates, e.g., growth rate, metabolic and genetic similarity, etc. Depending on the nature of the study, identify candi date organisms for TB, but may include: M . bovis (BCG), H37Ra, M. avium, M . intracellulare, M. terrae, M. phlei, etc.

C O N TR O L TEC H NO LO G Y

Most o f the other research objectives identified by the Workshop will produce recommendations for improvements in the near and distant future. Research on, or immediate application of existing control technologies may reduce the incidence of infections immediately. To improve on infection controls, research on the effectiveness o f various control technologies, individually and in combination, is needed. Control strategies currently proposed include ventilation (local and general), HEPA filtration, ultravio let germicidal irradiation, and respiratory protection. Efficacy needs to be proved. Some specific objectives include: Investigate innovative technologies for control. Assess germicidal agents on infectious aerosols (ozone, formaldehyde, hydrogen peroxide, andC102). Assess the effects o f turbulence and convection on control systems.

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Research Recommendations
F IL T E R P E R F O R M A N C E

The efficacy o f filtration, including HEPA filters, and the use of respiratory protective equipment needs to be assessed. Evaluate the penetration and viability of organisms as they pass through filters. Research objectives include: * Determine if microbial particles behave differently than normal filter test aerosols, i.e., com oil (filter penetration). For those particles passing through filter materials, determine bow their viability is affected by the experience (defined as the ability to reproduce and amplify). Ev aluate re-aerosolization of microbial aerosol s from the collection-side of the filter media during mainte nance or when otherwise disturbed.

R E S U S P E N S IO N

Assess survivability of infectious agents on surfaces, clothing, bedding materials, etc., which may be contaminated with infec tious agents and have the potential to be re-aerosolized. Settled particles could become reentrained by vacuuming or through disinfection or decontamination procedures, or other activities creating a potential exposure. Research should also focus on fungi for aerosolization from surface growth.

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Research Recommendations
R E S E A R C H S O U R C E R E C O M M E N D A T IO N S F O R S O U R C E

C H A R A C T E R IZ A T IO N

A N D

C O N T R O L

INTRODUCTION In the case of airborne infections, the major source of exposure (with some exceptions to be discussed below) is a person, usually at a health care facility. The process that produces the "airborne infection is also very dynamic. Levels of production appear to increase and decrease with little predictability, unlike many manufacturing processes. Despite this unpredictable nature, infection control personnel have been relatively successful in the past at controlling exposure to airborne infections in healthcare facilities. Dr. Melius believes that most of the success in this area does not result from the usual techniques used in occupational health such as exhaust ventilation, personal protective equipment, etc. Rather, our colleagues in communicable disease and infec tion control have achieved this control by identifying potential sources of infection and isolating this potential source. This source identification and control has been a major accomplish ment and should be recognized as the key step in controlling transmission of tuberculosis in health care facilities. A few terms that were discussed and defined up front included health care facilities, related facilities, workers, and workeracquiredinfections. The term health care facilities1includes, but is not limited to, hospitals, clinics, group practices, private physician *s offices, homes (home care), community and medical laboratories. The term related facilities* includes, but is not limited to,congregate living quarters, corrections facilities (jails, prisons, and holding areas), autopsy/morgue facilities, substance abuse centers, transportation vehicles, laboratories, social service centers, nursing homes, and medical waste facilities. The term worker includes, but is not limited to, health care workers (medical and reception/registration staff), emergency medical services personnel (first responders), corrections personnel, social

155

Research Recommendations
workers, housekeeping staff, laboratory workers, facilities personnel, volunteers, and students. Following a brief review of Dr. Eickhoff s plenary paper on airborne infection, the panel discussed which organisms (bacteria, fungi, and viruses) associated with airborne nosocomial infections have been implicated in occupatiamUy acquired aiiborne infections. The following organisms bave been implicated as potential occupatianally acquired infections in workerswho arenon-immunocompromised: respiratory syncytial virus, Varie ell a-zoster virus, Parvovirus, Mycobacterium tuberculosis, and Legionella pneumophilia. Given the current importance o f tuberculosis, particularly multidrug-resistant tuberculosis, a majority of the discussions and recommendations focused on tuberculosis transmission. Research recommendations for source characterization and con trol are the result o f in-depth discussions by this scientific panel. While some o f the recommendations may overlap those from other panel sessions, all are included in this summary. The panel developed five general areas of research and program control recommendations: Identification of infectious sources Epidemiology and surveillance studies Engineering and procedural controls and work prac tice modification Training and education Recommendations not otherwise classified

The recommendations have been subdivided into three major priority groupings: highest priority, high priority, and priority.
ID E N T IF IC A T IO N O F IN F E C T IO U S S O U R C E S

The major source for the transmission of airborne infections in health care and related facilities is infected persons. Bacteria or viruses may be exhaled as the person talks, coughs, or sneezes. Microbial contamination of ventilation systems, while a contrib uting factor in potential nosocom ial infections in

156

Research Recommendations
immunocompromised persons, has not been commonly reported in health care workers as a result of work-related exposures. Thus, prompt identification of infectious individuals is of utmost impor tance. Following are the Panel's recommendations: * Develop rapid and accurate (specific and sensitive) methods for diagnosing infections capable of being transmitted by the airborne route. Develop real-time TB breath analyzer. Highest Priority. Develop strategies for the early triage, identification, isola tion, and diagnostic testing (e.g. acid-fast bacillus [AFB] smears, polymerase chain reaction [PCR], etc.) of individuals who have infectious TB. Highest Priority. Evaluate sensitivity, specificity, and variability of current purified protein derivative (PFD) preparations and protocols for the identification of persons infected with M . tuberculosis.

Highest Priority. *
Develop improved skin test reagents (or other methods), for M. tuberculosis (increase sensitivity and specificity of exist ing tests), and for the identification of infection with Myco bacteria other than tuberculosis. High Priority. Develop a better understanding of the potential for infection from organisms capable of airborne transmission that may remain viable for long periods of time on surfaces, and evaluate appropriate methods of disinfection. Priority.

E P ID E M IO L O G Y A N D S U R V E IL L A N C E S T U D IE S

The following recommendations relate to the study of transmis sion o f various infectious diseases as they spread and the factors that may contribute to disease transmission. * Evaluate the adequacy of infectious disease surveillance sys tems (i.e., identification o f patients known to be infected) in local and state health departments. In particular, develop 157

Research Recommendations
procedures to ensure the appropriate institutions are notified so that persons with infectious tuberculosis are immediately identified. Highest Priority, Establish a prospective surveillance system for tuberculin skin test conversions in health care facilities (e.g., possibly National Nosocomial Infection Control System-based [NNISbased]). This system should include assessment of controls already in place and tbeir effect on skin test conversion rates and the clinical course of skin test converters. Highest

Priority.
Conduct follow-up studies o f exposed workers to better un derstand the sources of airborne infections and the efficacy of current control procedures* Highest Priority. Conduct epidemiologic studies o f worker tuberculin skin test conversions in related facilities1 ' to identify the risk of acquiring TB infection in these settings. High Priority.

E N G IN E E R IN G A N D P R O C E D U R A L C O N T R O L S

Many of the source control methods used to prevent airborne transmission of infectious diseases involve procedural as well as engineering methods of controlling exposures. Although the focus of this panel was source characterization and control, this panel did engage in a limited discussion of respiratory protection. This discussion and the recent CDC draft guidelines resulted in one of the recommendations contained in this section. In addition, recommendations for research into engineering and procedural controls follow: Evaluate existing and develop novel control methods for special high risk procedures such as sputum induction, bronchoscopy, patient transportation, etc. which may involve the utilization of specialized ventilation or local exhaust

158

Research Recommendations
systems. Parameters to be evaluated include application, performance, placement, and maintenance o f ventilation sys tems and other controls. Employee training programs, stan dardized test methods for in situ evaluation of controls, and user acceptability criteria should be developed. Highest Priority. Evaluate efficacy of recirculation units (i.e., in-duct air filtration and ultraviolet germicidal irradiation [UVGI]) in pre venting and controlling airborne tuberculosis transmission via field evaluations and epidemiologic studies. Develop performance, placement, maintenance, employee training, user acceptability, and evaluation criteria (via laboratory and field studies) for these units. Highest Priority. Evaluate auxiliary exhaust units.(i.e., in-duct or in-room, ventilation systems used to augment general ventilation) via field evaluations and epidemiologic studies. Develop perfor mance, placement, maintenance, employee training, user ac ceptability, and monitoring criteria* Highest Priority. Develop performance criteria and testing protocols for por table, stationary, and in~duct high efficiency particulate air (HEPA) and ultra low penetration air (ULPA) filtration units (e.g., using criteria set forth in the National Sanitation Foun dation Standard Number 49, Class II (Laminar Flow) Biohaz ard Cabinetry as a model [NSF 49] or other applicable stan dards). Highest Priority*

Evaluate airflow patterns within the rooms and their impact on local variation of infectious aerosol concentration within the rooms. Parameters to consider include airflow rate, tempera ture, relative humidity, initial concentration, equipment in rooms, location of supply/exhaust, configuration of rooms, and location of in-room HEPA filtration and dynamic UVGI units. Highest Priority.

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Research Recommendations
* Develop a national respirator task force to discuss and make recommendations on the types and use o f respirators by patients, health care workers and visitors. The major focus of the task force should include acceptability issues,compliance, knowledge of respirators, worker training, and respirator designs. The efficacy o f using surgical masks or valveless respirators by infectious tuberculosis patients as a source control should also be evaluated. The proposed CDC guide lines recommend the wearing of a surgical mask by the patient outside of the tuberculosis isolation room. A workshop similar to this one should be conducted to develop a national research agenda on respiratory protection for workers ex posed to infectious aerosols or droplets. Highest Priority. Evaluate performance and provide information on available filters and filtration systems* Issues to be addressed include bioaerosol penetration (both filtration efficiency and passive transport through moist filter material), amplification of mi' croorganisms in the filter material, and viability of microor ganisms on and within the filtermaterial for extended periods. High Priority. Evaluate personal safety and efficacy issues of UVGI disin fection of air (i.e., upper-air and in-duct irradiation). High

Priority.
Evaluate the adequacy of the Wells-Riley equation for esti mating the risk of acquiring tuberculosis infection and modify the equation, if necessary. Use this equation to assess the effectiveness of different control mechanisms in removing infectious droplet nuclei from room air. Priority. * Conduct hazard assessment of medical waste disposal work ers at health care and medical waste disposal facilities. Prior ity - minority opinion.

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Research Recommendations
TRAINING AND EDUCATION
Training and education are important factors in an infection control program. Evaluation and revision of current materials and techniques are needed to meet the objective of preventing the transmission of all infectious agents. Develop curricula to provide multi-disciplinary training to institutional staff with responsibilities for infection control programs (including tuberculosis control), including practi tioners in infection control, industrial hygiene, and facilities engineering, and provide training on a regional basis, as needed. Highest Priority. Develop, evaluate, and disseminate a training program on infection control (culturally and educationally appropriate) for patients, clients, inmates, workers and others. Different programs will be required for different types of facilities.

High Priority.
R E C O M M E N D A T IO N S N O T O T H E R W IS E C L A S S IF IE D

This final section includes recommendations which did not fall under one of the other four major areas of research. Issues which need to be addressed include special considerations of individuals (i.e., individuals covered under the Americans with Disabilities Act [ADA]), compliance with infection control procedures, and overall management of an infection control program, Evaluate factors related to patient and others compliance with isolation and other infection control procedures, identify potential barriers to compliance, and develop strategies to improve compliance. Highest Priority. Determine lowest achievable risk of occupationally acquired tuberculosis infection, as measured by tuberculin skin test conversion, adjusted for varying prevalence of tuberculosis infection in the population. Highest Priority.

161

Research Recommendations
Develop a mechanism to reach agreement on acceptable risk of acquiring occupational airborne infections (especially tu berculosis). Highest Priority.

Develop guidelines for reasonable accommodation, as de fined by the Americans with Disabilities Act (ADA), for immunocompromised workers potentially exposed to infec tious aerosols (including M . tuberculosis). Highest Priority. Develop an understanding of the indicators of susceptibility and disease progression for immunocompromised workers to facilitate their personal decision-making regarding the use of protective measures, etc. High Priority. Study the institutional and organizational factors that impact upon the implementation (or non-implementation) of sound airborne infection identification, prevention and control pro grams. High Priority,

R E S E A R C H B U IL D IN G

R E C O M M E N D A T IO N S

O N

D E S IG N S

IN T R O D U C T IO N

It is imperative that consideration to specific issues be addressed before a national research agenda can be established and implemented. These issues include building designs that are based on appropriate risk assessment, prevention ofhysteriaand over-reaction, consideration of humanistic concerns, building designs by multi-disciplinary teams, appropriate public and private sector educational programs, uncomplicated system designs and maintenance programs, the development of standards as performance criteria, and building construction incorporating system maintenance concerns.

162

Research Recommendations
Building and system designs should be based on comprehensive risk assessment and scientifically proven control techniques. In this way, hysteria and over-reaction can be assuaged without minimizing the significance of tuberculosis and other airborne diseases. There should be an understanding where areas of exposure occur, an understanding of the resultant risk to staff and patients* an appreciation of the differing needs of inner city centers versus those in rural communities, and more meaningful methodologies and approaches than are currently being used (i.e., the one isolation bed per thirty general medical-surgical beds cook book ratios). Caution should be exercised with the whole sale application ofblackbox technologies (i.e., ultra-violet germi cidal irradiation and portable high efficiency particulate air [HEPA] filtration devices) whose efficacy are uncertain. Design criteria must incorporate humanistic concerns. Most importantly, the disruption between the health care worker and the patient should be minimized* Environments should include fac tors to mitigate potential discomfort and deprivation from hard surfaces and equipment noise* Designs should respond to the ergonomic needs of patients and staff; infection control banners and measures should not make patient care or interaction physi cally cumbersome. It is important to recognize the special needs of select patient populations. Specifically, attention must be paid to patients with longer lengths of stay (possibly up to one year or more), to patients who are involuntarily confmed, and to those patients from special populations (i.e., mental health or prisons). The design of new health care facilities (or the renovation of existing ones) must be the coordinated effort of a multi-disciplinary team. The design team should include engineers from the start of the project (including the conceptual stages), through the architectural design, and to the final commissioning of the building and systems. Additionally, the team should include representation from the infec tion control service to help educate other members o f the team on the need for control measures, to evaluate proposals, and to select the most appropriate methods of control, fivery member of the team should understand all the project objectives.

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Research Recommendations
No program can be successful without extensive ducation of those involved in the design and construction process, as well as those who will ultimately use the facilities. Appropriate educa tional programs should include the users (specifically, nursing personnel, allied health staff, and physicians), building and sys tems designers, maintained, patients, and visitors. Effective educational programs must encompass several target points: designing the facility, commissioning the building* devel oping ongoing in-service programs, and caring for patients. The design basis and operational systems must continually be evalu ated and explained to those involved in theiruse and maintenance. Along these lines, the successful education o f maintenance per sonnel will hinge on the complexity of system designs. As funds spent on maintenance decrease, systems must be designed with a minimum of steps and sophisticated procedures in order to allow less educated or skilled personnel to accomplish needed routine maintenance and repair with less frequent activity (i.e., keep

design and systems simple).


Building system components should be designed as systems with overall performance criteria instead of individual, discrete component standards. Documentation from this approach should allow users and maintained over the life of the building to understand the implications of modifying a component on the whole system. Additionally, building construction must incorpo rate system maintenance concerns. As construction funds be come tight, owners often cut back on building systems. This approach can negatively affect the ability to provide infection control systems. All parties to the design and construction process should understand the trade-offs" between first and lifetime operating costs and efficienciesespecially since construction costs are only a small percentage o f the total cost o f maintaining a building over time. The space allocated to mechanical and electrical systems should be adequate to allow maintenance and repair; periodic maintenance and repair should not have to be compromised because of cramped access.

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Research Recommendations
R E C O M M E N D A T IO N S

Develop immediate interim methods for improved worker and patient protection until new construction, renovation, and/or initiatives are developed for medical centers and re lated facilities such as homeless shelters, ambulatory care, methadone clinics, etc. Development of methodologies to calculate the number of in patient acute and intensive care infectious isolation rooms on a regional health planning basis and hospital or network-wide. Also methodologies need to be established to identify those: Hospital-based ancillary services needed to support that population including diagnostic and treatment facilities. Alternate care delivery sites such as schools, shelters, residential treatment centers, etc., to support that population.

Develop criteria and programming needs for the layout and location of infectious isolation and related facilities such as: Emergency Departments, Clinics, Imaging, Oral Surgery/ Dental, Sputum Induction/Pentamidine, Administration, Morgue/Autopsy Suite, Surgery and Recovery, Endoscopy, Respiratory Therapy, 23-Hour Unit, Prenatal, and Labora tory. For each of these areas: Specific items to consider are (but not all-inclusive): staffing, additional space needs, and location of rooms to ancillary services. Develop specific programming and design criteria considering the physical layout and related equip ment requirements. Items to consider are (but not allinclusive): Furniture, finishes, square footage, seal ing of room, operable versus fixed windows, moni toring of airflow, and equipment, etc.

165

Research Recommendations
Develop space criteria for appropriate mechanical system maintenance, repair, and replacement. Develop coordinated regul alion s consider! ng airborne infection controls fire and life safety, energy conser vation (potential BTU tax), and the Americans with Disabilities Act. Balanced against health care risks, determine the need for black box technology (e.g., UV and inroom HEPA units) and other methods for air disinfec tion and contaminant removal. If affirmed, establish design criteria for proper installation and operation. Specific to isolation suites (consider the necessity for providing an anteroom): Are airlocks required to maintain negative or positive pressure? Is the space necessary as a work and storage area in which to practice infection control? If an anteroom is provided, can it be shared between two infectious isolation rooms? Assess the need for positive (out) airflow from the room. (Are reversible systems recommended?) Establish strategies for converting existing buildings to meet the criteria and programmatic needs of protect ing health care workers and patients from airborne infections. Study the effect on heallh care and/or social service workers with prolonged or repetitive contact with high risk clients. If determined necessary, develop design and programming criteria for special consid erations for that population.

166

Research Recommendations
Research the probability of workers and clients acquiring airborne infections in overcrowded conditions (e.g., places of assembly, transportation, homeless shelters, day room, etc.). Determine the appropriate design criteria and technology for areas where sputum induction, administration of aerosolized medications* and other high risk procedures are performed, such as booths, specialized rooms or enclosures (bronchoscopy and pentamidine administration). Develop the performance criteria for designing facilities for patients having a long-term need for treatment or isolation (e.g., need for living space, recreational facilities, movement around the facility): Patients in non-compliant detention Patients where isolation is required Correctional facilities,-e.g., jails, prisons, and holding facilities Develop design criteria for prolonged contact waiting spaces (e.g., initial patient screening, emergency department holding areas, public waiting spaces, etc.).

167

Research Recommendations
R E S E A R C H V E N T IL A T IO N R E C O M M E N D A T IO N S D E S IG N S F O R

IN T R O D U C T IO N

Effective control of the spread o f airborne infectious diseases in health care and related facilities will necessitate the use of a variety of techniques including ventilation. Ventilation techniques for main tenance of indoor environmental quality have some application. However the unique characteristics of airborne infectious diseases in the health caie setting such as lack of quantitative information on contaminant generation, low contaminant levels, mobility of the infection source, and difficulty of idenfication require that new ventilation techniques and application criteria be developed. Research recommendations for ventilation techniques for controlling the spread of M . tuberculosis in health care facilities were developed by a panel of experts with experience in control of infectious diseases in health care facilities* The panel began its discussion following a plenary presentation on health care ventilation by Richard Hermans and Andrew Streifel. The followingresearchtopics shouldbeaddressed in developing ventilation design and operating parameters: Pathogen generation rates and concentration control levels Identification of ventilation rates Distribution of general ventilation airflow Local exhaust ventilation Filtration Containment Maintenance Performance monitoring Ventilation control system design Side effects of engineering controls Role of ultraviolet irradiation in infection control Sampling and testing methods Interdisciplinary communication Comprehensive control study

168

Research Recommendations
D EVELO P V E N T IL A T IO N D E S IG N A N D O P E R A T IN G

PARAM ETERS

Pathogen generation rates and concentration control levels the application of effective control technology requires knowl edge of the level of contaminant being generated and a concen tration level to control to. These levels arc not well known for airborne infectious organisms and need to be determined. Identification of ventilation rates Distribution of general ventil ation airflow research is needed in several areas associated with general ventilation. The Wells-Riley equation provides the probabil ity of infection using a mathematical relationship between contaminant generation rate, room venti lation rate, the number of infected patients, pulmo nary ventilation rate and time. Research is needed to determine the feasibility of utilizing this equa tion to establish appropriate ventilation rates. Currently available criteria for general ventilation in the health care facility are primarily based on comfort considerations. Airflow rates are pro vided primarily for hospital settings. The effect of airflow level in reducing contaminant levels in a space needs research. Airflow distribution is not addressed other than the recommendation for air to flow from areas of higher^ contaminant concentration to areas of lower contaminant concentration. Very little information is available for health care areas other than the hospital. Detailed information is needed on the effects o f distri bution such as compari son of displacement vs. dilution ventilation.

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Research Recommendations
It is noted that the above areas can be effectively researched as individual entities but effective con trol will necessitate some combination of all three. Local exhaust ventilationlocal exhaust can consist of open exhaust hoods placed near a patient, patient enclosures and portable cleaning devices. Research is needed to apply the open type hoods to treatment procedures such as bronchoscopy. Research is needed to determioe efficacy o f portable cleaning devices and to develop standards for maintenance and opera tion of both patient enclosures and portable cleaning devices. Filtration filtration can be effectively used to remove con taminants from air exhausted from rooms, patient enclosures, portable cleaning devices* or other local exhaust hoods. Re~ search is needed to determine application and effectiveness of filtration for various infectious disease organisms In addition research is needed to evaluate the safety aspects o f filter maintenance including determination of the viability o f infec tious disease organisms trapped in the filter housing media and procedures for safe removal* handling and disposal of the used filters. Containmentcontainment by use of isolation can be effec tive if properly utilized. There are however questions regard^ ing the proper airflow balance in a room to achieve adequate levels o f negative pressure and the need for ante rooms (and ante room airflow balance) to prevent escape of contaminant from the room during ingress and egress. Research to evaluate these questions and to develop criteria for isolation room negative pressure is needed. M aintenance g uidelines and performance mo nitori ng poor maintenance and lack of performance monitoring criteria are common problems with ventilation systems and are often the cause of poor system performance. There is a need to develop

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Research Recommendations
maintenance guidelines focused on health care ventilation systems which can be readily implemented to prevent system breakdown. There is also a need for the development of system monitoring techniques which can identify and warn of potential system performance degradation. * Ventilation control system design the overall operation of a facility ventilation system is dependent on maintenance of airflow rates and area pressures throughout the entire facility. Maintaining these parameters in proper balance is necessary to achieve the desired ventilation condition. Review of the system controls necessary to achieve and maintain this bal ance for the unique conditions of the health care setting is recommended. Side effects of engineering controlsthe application o f engi neering controls (such as patient enclosures) may have ad verse effects on the patient and may result in rejection of the control. It is recommended that a study of the side effects of existing and new engineering controls be made to identify acceptance problems and to recommend corrective proce dures which will aid in acceptance of the control. Role o f ultraviolet irradiation in infection control ultravio let irradiation has long been utilized as a control for airborne infectious diseases in the health care setting. There are, however questions regarding its efficacy and safe operation. It is recommended that a study be conducted to evaluate the efficacy of UV in killing airborne infectious organisms and to develop parameters (dose response) to permit its effective application. Recommendations also need to be developed for safe operation and maintenance. Sampling and testing methods available sampling and tests methods for a wide range of airborne infectious organisms are for the most part not suitable for field sampling and for the evaluation of control performance. There is need to develop

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Research Recommendations
s a m p l i n g a n d testing m e t h o d s w h i c h will pro v id e real t im e or ear real t im e determination o f c o n t a m i n a n t levels. T h e r e is also n e e d to identify a n o n - p a t h o g e n i c surrogate for testing a n d evaluation o f control m e t h o d s . * Interdisciplinary c o m m u n i c a t i o n m a n y o f the control

strategies a n d research areas necessary for the health care area are c o m m o n w i t h other areas including b o t h the industrial a n d indoor environmental areas. Transferof this information b e t w e e n areas has not occurred to a n y extent It is r e c o m m e n d e d that the feasibility o f a health care control technology data base be investigated. Control solutions f r o m a w i d e range o f areas should b e studied and, if feasible, b e developed.

C o m p r e h e n s i v e Control S t u d y control of airborne infec tious disease is d e p e n d e n t o n the application o f a n u m b e r o f control m e t h o d s a n d w o r k practices* W h i l e the effectiveness o f a n individual control m a y b e d e t e r m i n e d in a laboratory setting, its individual contribution in practice m a y b e difficult to quantify. It is r e c o m m e n d e d that a control study b e p e r f o n n e d in the health care setting to validate the c umulative effect o f a c o m p r e h e n s i v e application o f control procedures ( e.g., ventilation, isolation, respiratory protection, administra tive p ro c e d u r e s etc).

172

SY N O P SIS

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Synopsis
M O R T O N U P P M A N N S Y N O P S IS

It has b e e n a n interesting a n d r e w a r d i n g three days. I've b e e n very gratified at the cooperative spirit at this W o r k s h o p . T h e p re c e d i n g P a n e l s u m m a r i e s w e r e d o n e so well that w e n o w h a v e g o o d lists o fthe critical questions. T h a t w a s o u r p r i m a r y task, a n d it has b e e n well met. F o r the W o r k s h o p as a w h ol e , I thought I m i g h t prepare a collective report card, s h o w i n g h o w well w e h a v e m e t the goals o f the P r o g r a m C o m m i t t e e a n d served the national need. I will then g o t h r o u g h s o m e other items o f a m o r e general nature. I will r e v i e w o u r a c c o m p l i s h m e n t s , a n d the a s s i g nm en t s w e s h o u l d take a w a y f r o m this exercise for future activity. Clearly, if w e d o n t carry-on w h a t w e started here, a lot o f the e n e r g y a n d effort that1s g o n e into this W o r k s h o p will h a v e b e e n wasted. Finally, I will deal w it h s o m e generic issues which; in m y personal view, arise f r o m these W o r k s h o p discussions. It is clear that the quality o f the P a n e l m e m b e r s hom e w o r k was excellent; W e h a d ve ry g o o d state-of-the-art papers, w h i c h e n abled the W o r k s h o p process to m o v e a h e a d expeditiously. M y observation in visiting e a c h o f the individual panels w a s that the level o f effort w a s certainly high, as w a s y o u r ability to w o r k together a n d share the k n o w l e d g e that e a c h o f y ou , as a specialist, b r o u g h t to e a c h panel. T h e topic o f S e a m a n s h i p w a s put in the report card o n the basis o f D i c k L e m e n s o p e n i n g r e m a r k s quoting Oliver W e n d e l l H o l m e s to the effect that the important thing is that w e k n o w w h i c h direction to sail, a n d to m o v e in the right direction in a difficult a n d s t o r m y s e a In this regard o u r report card i t em A d v a n c e m e n t to the next l e v e r warrants a g o o d grade. T h e critical issue for the future is w h e t h e r w e are g o i n g to w o r k effectively o n o u r follow-on activities. W h a t have w e accomplished? Collectively, w e h a v e a better

appreciation for the nature a n d extent o f airborne transmission o f infections, the role o f facility design a n d m a i n t e n a n c e in airborne

175

Synopsis
disease transmission of infections, the control options, and, to s o m e degree, the per fo rm a nc e o f o u r tools, i.e., source control, local exhaust ventilation, air purification, a n d controlled distribution o f airflow. W e h a v e co m pi le d a c o m p r e h e n s i v e list o f research needs, a n d in s o m e but not all cases, w e h a v e identified those for w h i c h research in the short term c a n help us address the p ro b l e m s that confront us today. W e also h a v e identified longer-term research needs. In addition, w e h a v e identified critical generic needs. Among

these are a n e e d for i m p r o v e d m e a n s o f c o m m u n i c a t i n g available k n o w l e d g e . IV s clear f r o m o u r discussions that o u r past efforts to reach the k e y target c o m m u n i t i e s h a v e not b e e n as effective as they n e e d to b e for effective control o f airborne transmission o f disease. Specific r e c o m m e n d a t i o n s include the preparation o f m a n u a l s a n d guidelines for distribution to the k e y target c o m m u nities. P e r h a p s the highest priority n e e d is that o f the m a i n t e n a n c e c o m m u n i t y , b e c a u s e o f the n e e d s b o t h to protect them, a n d to ena bl e t h e m to protect others* T h e y are bo th apopulation-at-risk a n d a population that affects risks. T h e m a n u a l s o f procedures m u s t b e in l a n g u a g e accessible to m a i n t e n a n c e personnel, a n d m u s t address w h a t to d o u n d e r n o r m a l conditions, as well as u n d e r e m e r g e n c y proce du re s w h e n things g o w r o n g . N o r m a l conditions refer to controlling air pressures, f l o w rates a n d directions. W h e n the air ha ndling s y s t e m s fail, o r other hospital e m e r g e n c i e s take placeT it is important to specify w h a t the m a i n t e n a n c e p e o p l e s h o u l d d o in order to protect the w o r k e r s a n d the patients. G u i d a n c e d o c u m e n t s also are n e e d e d for n o r m a l a n d e m e r g e n c y conditions for direct patient contact personnel; i.e., the nurses, m e d i c a l technicians, a n d physicians. Finally, the administrative a n d custodial personnel, w h o h a v e o nl y indirect contact, n e e d to h a v e g u i d a n c e for protecting themselves. O n the administrative side, they also n e e d to see to it that other personnel receive all the protection that is feasible. W e , collectively, h a v e a critical n e e d for a c o n s e n s u s building. O n e task is to assure f o ll o w- up o f the initiatives f r o m this

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Synopsis
W o r k s h o p . M y sense is that a l mo s t all o f y o u agree that this h as b e e n a successful start in a process to build consensus. W h a t else c a n C D C / N I O S H d o in particular? W h a t c a n other g r o u p s d o ? W h a t c a n w e d o individually to take a d v a n t a g e of w h e r e w e are? W e c a n address regional g r o u p s o n the n e e d for w o r k s h o p s a n d seminars. W e also c a n establish a n d maintain contacts wi th our professional colleagues, as well as w it h e a c h other, in order to k e e p u p s o m e m o m e n t u m for further progress. W h a t are o u r a s s i g n m e n t s ? W h a t c a n this g r o u p do, a n d w h a t c a n w e e n c o u r a g e others to d o ? O n e r e c u n i n g t h e m e in all o f the panels that I visited w a s a limited access to relevant unp ub li s he d k n o w l e d g e , especially the personal k n o w l e d g e o f exp er i en ce d colleagues. It s e e m e d to m e m u c h o f that valuable personal k n o w l e d g e a n d experience is publishable, at least as technical notes. T h e

Am erican In d u stria l Hygiene Association Journal a n d A p p lie d Oc cupational and Environm entalHygiene havesections specifically for
Applications Notes, w h i c h d o n t ha v e to m e e t the criteria applicable to a full research paper* B a s e d o n s o m e of the discussions w e h a v e h a d here, perhaps e ac h o f y o u could g o b a c k to y o u r files a n d find s o m e t h i n g that y o u could a d d to the literature. If so, try to get it into the published literature, at least as a technical note. If m o r e s u c h information w a s generally available, w e w o u l d n t h a v e to get so m a n y individuals together in a r o o m in order to begin to a s semble useful guidance* S u c h informal e x c ha ng es will al wa y s b e i n c o m plete, be ca us e only a limited n u m b e r of people with appropriate k n o w l e d g e will b e present in that r o o m . Publishable technical notes ca n b e b a s e d o n population-distributions of exposures, conversion rates, disease incidence, a n d influence o f the various factors that affect them. O n the efficacy of engineering controls, there clearly w a s a lot m o r e anecdotal data that w a s k n o w n to the p e o p l e in the r o o m , but not published, than s h ou l d b e the case. T h e s a m e c o u l d b e said for data o n the efficacy of administrative a n d personal e x p o s u r e controls. I therefore challenge e a c h o f y o u to d o w h a t y o u c a n to a d d to the b o d y o f literature a n d to e n c o u r a g e others to d o the s a m e . I also challenge y o u to e n c o u r a g e further c o m m u n i c a t i o n not on l y w i t h

177

Synopsis
y o u r colleagues, but w it h those p e o p l e w h o are at risk o r affect risk. M y c o m m e n t s o n the generic research issues m o r e or less follow f r o m the nature o f the fo rm a t for the panels. O n e m a j o r issue discussed w a s the analytical capabilities for e x p o s u r e evaluation in t e r m s o f b o t h s a m p l i n g a n d analysis. A n o t h e r m a j o r issue that w a s discussed, but not resolved, is h o w m u c h control is n e e d e d for disease prevention. preventing airborne transmission o f disease. Th i s refers to controls, not for their o w n sake, but for the p r i m a r y p u r p o s e o f W e recog ni ze d a n e e d for a higher level o f control w h e n w e re dealing wi th c o m p r o m i s e d individuals, a m a j o r consideration in health care facilities. W e shouldn't b e satisfied if w e m e r e l y protect the healthy individual, b e c a u s e there are too m a n y p e o p l e in current society, especially in the hospital setting, w h o are c o m p r o m i s e d . C o s t c o n t a i n m e n t is clearly a m a j o r issue o f the day. A n o t h e r is risk assessment, to pro vi d e a basis for risk m a n a g e m e n t decisions. S i n c e there isn t a n infinite s up p l y o f either research dollars, or dollars available for addressing the control needs, w e m u s t c o m e to grips with w h a t is a n acceptable level of control at a practical price. In this regard, the T L V concept w a s discussed. M a n y people criticize the occupational threshold limit values as b eing less than satisfactory because they only provide a basis for protecting nearly all" workeis. S o m e s eg m e n t s o f society believe that there should b e n o limitation o n h o w far w e should g o to protect the m o s t sensitive individuals. In practice, w e are g o i n g to h a v e to m a k e s o m e decisions a b o u t h o w far a l o n g that c o n t i n u u m w e are willing to c o m m i t o u r o w n a n d the public resources. W h a t is the extent o f control that is achievable? F o r the near

future, resource constraints will necessitate a focus o n retrofit a n d renovation, rather than construction o f n e w facilities. W h a t is the extent o f control that c a n b e ac h i e v e d b y patient isolation, a n d h o w far c a n w e g o in this area b e c a u s e o f the technical limitations or ethical constraints? W h a t a b o u t the applications o f e m e r g i n g t e c h n o l o g y ? In his P a n e l S u m m a r y ,

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Synopsis
B e n L i u said w e s h o u l d n t b e fully satisfied until w e h a v e direct reading instruments that tell us n o t o nl y the concentration o f T B bacteria, b u t w h e t h e r they re d e a d or alive. Clearly, h e w a s n t suggesting that as a goal that w a s achievable a n y t i m e soon. H o w e v e r , if w e d o n t h a v e long-range targets in m i n d , w e w o n ' t m a k e m u c h progress. W h a t can w e d o in terms o f the e m e r g i n g control technology? Clearly, there are targets of opportunity in this area, since the control engineers h a v e increasing capabilities bec a us e o f the nature a n d l o w cost o f microprocessor controls for ventilation systems. M y topic outline for these c o n c l u d i n g r e m a r k s i nc l u d e s

telemedicine. T h i s w a s stimulated b y a front p a g e story of yesterday s New York Times (Thursday, July 15). It contained blue s k y speculation about the role o f v i d e o in the hospital a n d health care setting. T h e hi g h definition e q u i p m e n t n o w available ( a nd the accessibility o f radiologic a n d other records) m a k e s it possible for m a n y o f the specialists in volved w it h patients to d o their thing without h a v i n g to travel to the hospital a n d without h a v i n g to b e e x p o s e d to the patient. W e can't a l w a y s isolate the patients so c o m p l e t e l y that they n e v e r see a n y caregiver. On-t h eother-hand, w e c a n certainly m i n i m i z e the u n n e c e s s a r y contact b e t w e e n accessory m e d i c a l personnel a n d the infected patient b y utilizing this n e w technology. In closing, I w a n t to note the skill a n d dedication p r o v i d e d b y e a c h of the m e m b e r s o f the panels a n d the contributing m e m b e r s o f their audiences in c o m i n g u p w i t h well-crafted a n d reasonably c o m p r e h e n s i v e research a g e n d a items. E v e n w h e n the issues c o u l d n t b e f r a m e d in terms o f research t h e m e s a n d topics, the discussions did at least get the questions out o n the table for the research c o m m u n i t y . K n o w i n g w h a t issues are important c a n help to f ocus research grant applications to N I H a n d other f u n d i n g agencies. I a m certainly pleased w i t h the o u t c o m e s of this pioneering effort. It has h e l p e d to stimulate interdisciplinary cooperation. I e nd o r s e the r e c o m m e n d a t i o n s that R i c k H e r m a n s presented a bout seeking

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Synopsis
m e c h a n i s m s to establish a n interdisciplinary oversight c o m m i t t e e to help us cross a g e n c y borders a n d to k e e p contacts w i t h those here a n d others. W e n e e d lo find a m e c h a n i s m , a n d a h o m e in o n e o f the g o v e r n m e n t agencies, for establishing the k i n d o f data base that h e w a s talking a b o u t for engineering data. Let's build u p o n his Panel's r e c o m m e n d a t i o n , a n d s e e k to establish a d a t a b a s e that c ov e r s the aspects c o v e r e d b y the other W o r k s h o p panels as well. i personally t h a n k y o u for everything that y o u all h a v e d o n e individually a n d collectively. I k n o w m y co-chair, Phil B i e r b a u m , also w a n t s to t h a n k yo u, a n d h e h a s s o m e closing r e m a r k s w h i c h follow.

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P H IU P

B IE R B A U M

S Y N O P S IS

W h a t I will d o for m y s u m m a r y is to try a n d identify f r o m the pane l s recommendations s o m e hot topicsthat Dr. L i p p m a n n a n d I will use in c o m p i l i n g the E x e c u t i v e S u m m a r y for these Proceedings. S o b ea r w i th m e as I g o through a n d highlight a c ou p l e o f k e y w o r d s f r o m the four panels. It is interesting that across these panels m a n y topics c o m e u p o v e r a n d over, e v e n t h o u g h w e h a d different sets o f experts o n e a c h o f the panels. T h e s e topics are (1) s a m p l i n g m e t h o d s ; (2) effective ness o f control technologies; (3) characterizing aerosols; (4) survivability o f infectious agents; (5) accessing the size, shape, a n d a e r o d y n a m i c properties o f infectious agents; (6) microbial ecology; (7) s a m p l i n g a n d analytical m e t h o d s ; (8) evaluating control technologies; (9) efficacy o f filtration; (10) m e t h o d s for d iagnosing infectious transmitters; {11) control m e t h o d s for s p e cial proce du re s within hospitals a n d other settings; (12) strategies for early triage; (13) evaluation o f recirculation units; (14) e v al u ation o f total exhaust units; (15) evaluation of filtration units; (16) evaluating airflow patterns; (17) patient c om p liance; a n d (18) multi-disciplinary training. A lot o f the r e c o m m e n d a t i o n s that w e r e d e v e l o p e d dealt w it h engineering controls. H o w e v e r , in the S o u r c e Characterization a n d Con tr ol Panel, itw a s recog ni z ed that there are m a n y administrative procedures that are n e e d e d w h i c h are not defined as engineering controls. I believe that a m a j o r issue w e h a v e to recognize is that it's not just health care facilities but other related facilities (e.g.* correctional facilities a n d social service facilities) w h e r e there are also e x p o sures for workers. Filters a n d filtration systems, efficacy o f disinfection, indicators o f susceptibility, validating the Wells-Riley equation also s e e m to b e ve ry important for these workplaces. A n o t h e r issue that w a s raised in the panels is that w e n e e d to w o r r y a b o u t e x p o s u r e to all w o r k e r s in these facilities, f r o m m a i n t e n a n c e w o r k e r s to the health care professionals. W e w a n t to deal w it h all workers, not just health care workers."

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Synopsis
A n e x t r e m e l y important issue that w a s raised is that there is a n i m m e d i a t e n e e d to deal wi th de v e l o p i n g s a m p l i n g a n d analytical m e t h o d s , a n d the fact that w e are not just trying to d e v e l o p a research ag en da , but that w e n e e d to d e v e l o p control solutions n o w . M e t h o d o l o g i e s to calculate the n u m b e r o f inpatient isolation a n d intensive care r o o m s ; a n d h o w to design intensive care r o o m s , isolation r o o m s , surgical suites, e m e r g e n c y r o o m s , etc. are e x tr e me ly important in geographical locations that h a v e h ig h risk populations. C o o r d i n a t e d regulations, w h i c h are consistent for these d es i g n criteria, are o n e o f the m o s t important issues that w e c a n he l p solve th r o u g h o u t o u r public health a n d health care systems. W e h a v e re c o g n i z e d this at C D C in o u r efforts to revise the 1 9 9 0 C D C Guidelines for Preventing the T r a n s m i s s i o n o f T uberculosis in H e a l t h C a r e Settings. W e n e e d to under s ta nd the usefulness o f a nt e r o o m s ; w e n e e d criteria for converting existing buildings ( w h i c h is e x t r e m e l y i mport an t for inner city health care facilities); w e n e e d to d e v e l o p d esi gn a n d p r o g r a m m a t i c criteria for special populations, (e.g., i m m u n o c o m p r o m i s e d w o r k e r s a n d patients) a n d for special m e d i cal proc ed ur es (e.g., administration of aerosolized medications); w e n e e d d e s ig n criteria for waiting spaces ( w h i c h is e x t r e m e l y i mportant b e c a u s e w e d o n t k n o w w h o is infected in these areas); a n d w e n e e d design criteria for social service areas, h o m e l e s s shelters, etc. W e n e e d to u n d e r s t a n d the efficacy of dilution ventilation, airflow patterns, a n d filtration units. W e talked a b o u t the n e e d to d e v e l o p a m a n u a l as w e h a v e in the industrial h y g i e n e c o m m u n i t y for industrial ventilation. W e n e e d a m a n u a l that includes m a i n t e n a n c e procedures. W e n e e d standard m e t h o d s for s a m p l i n g a n d analysis. Also, as Dr. L i p p m a n n ment io ne d, w e n e e d a database o f scientific a n d c o m m o n s e ns e solutions. T h a t is pretty m u c h a s u m m a r y o f the hot i t em sthat I h e a r d c o m i n g u p o v e r a n d over.

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Synopsis
T o repeat for e mp ha si s , it is a v e ry important for us to u n d e r st an d a n d utilize the expertise f o u n d in the infection control practitioner c o m m u n i t y , the occupational health c o m m u n i t y , a n d the engineer ing/architecture c o m m u n i t y ( wh i c h is different than the industrial hygiene c o m m u n i t y ) a n d to understand h o w w e c a n w o r k together to solve this w o r kp la c e problem. This w h o l e issue o f collaboration across these g r ou ps is unbelievably important b e c a u s e of resource limitations a n d the n e e d to eliminate duplication o f effort. W e h a v e to unde rs t an d that w e d o n e e d s im p l e solutions n o w , in addition to the d e v e l o p m e n t o f a short-term a n d l o ng -t e rm re search agenda. A s Dr. L i p p m a n n pointed out, w e k n o w so m u c h f r o m other arenas in occupational safety a n d health; w e k n o w so m u c h as individuals a n d groups, but the information is not getting out it is not b e i n g published. W h a t are these case studies about, w h a t d o e s w o r k , a n d w h a t d o e s not w o r k ? 1 appreciate e v e r y b o d y that c a m e a n d h e l p e d us at the w o r k s h o p . W e h o p e that w e c a n d e v e l o p s o m e m o m e n t u m f r o m the P r o c e e d ings a n d the interactions that h a v e taken place at the w o r k s h o p . It is often ve ry difficult, b e c a u s e w e g o b a c k a n d start w o r k i n g o n other things, but w e d o h a v e a goal to u s e this w o r k s h o p to d e v e l o p initiatives, to d e v e l o p a better collaborative approach. I w a n t to t h a n k Dr. L i p p m a n n as m y co-chair a n d as the individual w h o h e l p e d generate the incentive for the w o r k s h o p w i t h Dr. Millar last year about this time at the B o s t o n industrial hygiene conference. 1 w a n t to p a y a special note of thanks to o u r key no te a n d plenary speakers. I k n o w it is difficult to write su ch papers, a n d they did give us a g o o d starting point. T h a n k y o u Dr. Eickhoff, M r . Wh eeler, Dr. Cole, Dr. Melius, M s . B u m s , M r . H e r m a n s , a n d M r . Streifel, I w a n t to thank the Panel Chairs a n d Rapporteurs, Dr. B e n Liu, M r . F r a n k Heart, Dr. Jane L i p s c o m b , M r . Pa ul Jensen, M r . D o u g Erickson, M r . K e n Martinez, M r . B o b H u g h e s , a n d M r . R i c k H e r m a n s . It a l w a y s is adifficuJttasktopull all the discussions

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Synopsis
together a n d k e e p panel m e m b e r s o n the s a m e track. A g a i n , I w a n t to t h a n k the P r o g r a m C o m m i t t e e for getting u s started; Dr. L a r r y D o e m e n y w h o is m y d e p u t y a n d w a s o u r technical coordinator; M s . R o z Kendall, w h o w a s o u r administrative coordinator a n d m a d e it all h a p p e n ;M s . Heather Hou s t o n w h o h e l p e d R o z ; a n d other staff at N I O S H ; M s . C h a r l e n e M a l o n e y a n d h e r staff; M r . B o b Mueller; M r . R o g e r W h e e l e r ; a n d the other staff w h o h el p e d in the panel r oo m s .

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