Assessing the effects of transient weather conditions on airborne transmission risk in naturally ventilated hospitals.

BACKGROUND: Many UK hospitals rely heavily on natural ventilation as their main source of airflow in patient wards. This method of ventilation can have cost and energy benefits, but it may lead to unpredictable flow patterns between indoor spaces, potentially leading to the unexpected transport of infectious material to other connecting zones. However, the effects of weather conditions on airborne transmission are often overlooked. METHODS: A multi-zone CONTAM model of a naturally ventilated hospital respiratory ward, incorporating time-varying weather, was proposed. Coupling this with an airborne infection model, this study assessed the variable risk in interconnected spaces, focusing particularly on occupancy, disease and ventilation scenarios based on a UK respiratory ward. RESULTS: The results suggest that natural ventilation with varying weather conditions can cause irregularities in the ventilation rates and interzonal flow rates of connected zones, leading to infrequent but high peaks in the concentration of airborne pathogens in particular rooms. This transient behaviour increases the risk of airborne infection, particularly through movement of pathogens between rooms, and highlights that large outbreaks may be more likely under certain conditions. This study demonstrated how ventilation rates achieved by natural ventilation are likely to fall below the recommended guidance, and that the implementation of supplemental mechanical ventilation can increase ventilation rates and reduce the variability in infection risks. CONCLUSION: This model emphasises the need for consideration of transient external conditions when assessing the risk of transmission of airborne infection in indoor environments.

Why is mock care not a good proxy for predicting hand contamination during patient care?

BACKGROUND: Healthcare worker (HCW) behaviours, such as the sequence of their contacts with surfaces and hand hygiene moments, are important for understanding disease transmission. AIM: To propose a method for recording sequences of HCW behaviours during mock vs actual procedures, and to evaluate differences for use in infection risk modelling and staff training. METHODS: Procedures for three types of care were observed under mock and actual settings: intravenous (IV) drip care, observational care and doctors' rounds on a respiratory ward in a university teaching hospital. Contacts and hand hygiene behaviours were recorded in real-time using either a handheld tablet or video cameras. FINDINGS: Actual patient care demonstrated 70% more surface contacts than mock care. It was also 2.4 min longer than mock care, but equal in terms of patient contacts. On average, doctors' rounds took 7.5 min (2.5 min for mock care), whilst auxiliary nurses took 4.9 min for observational care (2.4 min for mock care). Registered nurses took 3.2 min for mock IV care and 3.8 min for actual IV care; this translated into a 44% increase in contacts. In 51% of actual care episodes and 37% of mock care episodes, hand hygiene was performed before patient contact; in comparison, 15% of staff delivering actual care performed hand hygiene after patient contact on leaving the room vs 22% for mock care. The number of overall touches in the patient room was a modest predictor of hand hygiene. Using a model to predict hand contamination from surface contacts for Staphylococcus aureus, Escherichia coli and norovirus, mock care underestimated micro-organisms on hands by approximately 30%.

Influence of ventilation use and occupant behaviour on surface microorganisms in contemporary social housing.

In the context of increasingly airtight homes, there is currently little known about the type and diversity of microorganisms in the home, or factors that could affect their abundance, diversity and nature. In this study, we examined the type and prevalence of cultivable microorganisms at eight different sites in 100 homes of older adults located in Glasgow, Scotland. The microbiological sampling was undertaken alongside a household survey that collated information on household demographics, occupant behaviour, building characteristics, antibiotic use and general health information. Each of the sampled sites revealed its own distinct microbiological character, in both species and number of cultivable microbes. While some potential human pathogens were identified, none were found to be multidrug resistant. We examined whether the variability in bacterial communities could be attributed to differences in building characteristics, occupant behaviour or household factors. Sampled sites furnished specific microbiological characteristics which reflected room function and touch frequency. We found that homes that reported opening windows more often were strongly associated with lower numbers of Gram-negative organisms at indoor sites (p < 0.0001). This work offers one of the first detailed analysis of cultivable microbes in homes of older adults and their relationship with building and occupancy related factors, in a UK context.

Pilot-scale biofiltration at a materials recovery facility: The impact on bioaerosol control.

This study investigated the performance of four pilot-scale biofilters for the removal of bioaerosols from waste airstreams in a materials recovery facility (MRF) based in Leeds, UK. A six-stage Andersen sampler was used to measure the concentrations of four groups of bioaerosols (Aspergillus fumigatus, total fungi, total mesophilic bacteria and Gram negative bacteria) in the airstream before and after passing through the biofilters over a period of 11 months. The biofilters achieved average removal efficiency (RE) of 70% (35 to 97%) for A. fumigatus, 71% (35 to 94%) for total fungi, 68% (47 to 86%) for total mesophilic bacteria and 50% (-4 to 85%) for Gram negative bacteria, provided that the inlet concentration was high (103-105 cfu m-3), which is the case for most waste treatment facilities. The performance was highly variable at low inlet concentration with some cases showing an increase in outlet concentrations, suggesting that biofilters had the potential to be net emitters of bioaerosols. The gas phase residence time did not appear to have any statistically significant impact on bioaerosol removal efficiency. Particle size distribution varied between the inlet and outlet air, with the outlet having a greater proportion of smaller sized particles that represent a greater human health risk as they can penetrate deep into the respiratory system where gaseous exchange occurs. However, the outlet concentrations were low and would further be diluted by wind in full scale applications. In conclusion, this study shows that biofilters designed and operated for odour degradation can also achieve significant bioaerosol control in waste gas.

Is there an association between airborne and surface microbes in the critical care environment?

BACKGROUND: There are few data and no accepted standards for air quality in the intensive care unit (ICU). Any relationship between airborne pathogens and hospital-acquired infection (HAI) risk in the ICU remains unknown. AIM: First, to correlate environmental contamination of air and surfaces in the ICU; second, to examine any association between environmental contamination and ICU-acquired staphylococcal infection. METHODS: Patients, air, and surfaces were screened on 10 sampling days in a mechanically ventilated 10-bed ICU for a 10-month period. Near-patient hand-touch sites (N = 500) and air (N = 80) were screened for total colony count and Staphylococcus aureus. Air counts were compared with surface counts according to proposed standards for air and surface bioburden. Patients were monitored for ICU-acquired staphylococcal infection throughout. FINDINGS: Overall, 235 of 500 (47%) surfaces failed the standard for aerobic counts (≤2.5 cfu/cm2). Half of passive air samples (20/40: 50%) failed the 'index of microbial air' contamination (2 cfu/9 cm plate/h), and 15/40 (37.5%) active air samples failed the clean air standard (<10 cfu/m3). Settle plate data were closer to the pass/fail proportion from surfaces and provided the best agreement between air parameters and surfaces when evaluating surface benchmark values of 0-20 cfu/cm2. The surface standard most likely to reflect hygiene pass/fail results compared with air was 5 cfu/cm2. Rates of ICU-acquired staphylococcal infection were associated with surface counts per bed during 72h encompassing sampling days (P = 0.012). CONCLUSION: Passive air sampling provides quantitative data analogous to that obtained from surfaces. Settle plates could serve as a proxy for routine environmental screening to determine the infection risk in ICU.

Relationship between healthcare worker surface contacts, care type and hand hygiene: an observational study in a single-bed hospital ward.

This study quantifies the relationship between hand hygiene and the frequency with which healthcare workers (HCWs) touch surfaces in patient rooms. Surface contacts and hand hygiene were recorded in a single-bed UK hospital ward for six care types. Surface contacts often formed non-random patterns, but hygiene before or after patient contact depends significantly on care type (P=0.001). The likelihood of hygiene correlated with the number of surface contacts (95% confidence interval 1.1-5.8, P=0.002), but not with time spent in the room. This highlights that a potential subconscious need for hand hygiene may have developed in HCWs, which may support and help focus future hygiene education programmes.

Modeling environmental contamination in hospital single- and four-bed rooms.

UNLABELLED: Aerial dispersion of pathogens is recognized as a potential transmission route for hospital acquired infections; however, little is known about the link between healthcare worker (HCW) contacts' with contaminated surfaces, the transmission of infections and hospital room design. We combine computational fluid dynamics (CFD) simulations of bioaerosol deposition with a validated probabilistic HCW-surface contact model to estimate the relative quantity of pathogens accrued on hands during six types of care procedures in two room types. Results demonstrate that care type is most influential (P < 0.001), followed by the number of surface contacts (P < 0.001) and the distribution of surface pathogens (P = 0.05). Highest hand contamination was predicted during Personal care despite the highest levels of hand hygiene. Ventilation rates of 6 ac/h vs. 4 ac/h showed only minor reductions in predicted hand colonization. Pathogens accrued on hands decreased monotonically after patient care in single rooms due to the physical barrier of bioaerosol transmission between rooms and subsequent hand sanitation. Conversely, contamination was predicted to increase during contact with patients in four-bed rooms due to spatial spread of pathogens. Location of the infectious patient with respect to ventilation played a key role in determining pathogen loadings (P = 0.05). PRACTICAL IMPLICATIONS: We present the first quantitative model predicting the surface contacts by HCW and the subsequent accretion of pathogenic material as they perform standard patient care. This model indicates that single rooms may significantly reduce the risk of cross-contamination due to indirect infection transmission. Not all care types pose the same risks to patients, and housekeeping performed by HCWs may be an important contribution in the transmission of pathogens between patients. Ventilation rates and positioning of infectious patients within four-bed rooms can mitigate the accretion of pathogens, whereby reducing the risk of missed hand hygiene opportunities. The model provides a tool to quantitatively evaluate the influence of hospital room design on infection risk.

Observing and quantifying airflows in the infection control of aerosol- and airborne-transmitted diseases: an overview of approaches.

With concerns about the potential for the aerosol and airborne transmission of infectious agents, particularly influenza, more attention is being focused on the effectiveness of infection control procedures to prevent hospital-acquired infections by this route. More recently a number of different techniques have been applied to examine the temporal-spatial information about the airflow patterns and the movement of related, suspended material within this air in a hospital setting. Closer collaboration with engineers has allowed clinical microbiologists, virologists and infection control teams to assess the effectiveness of hospital isolation and ventilation facilities. The characteristics of human respiratory activities have also been investigated using some familiar engineering techniques. Such studies aim to enhance the effectiveness of such preventive measures and have included experiments with human-like mannequins using various tracer gas/particle techniques, real human volunteers with real-time non-invasive Schlieren imaging, numerical modelling using computational fluid dynamics, and small scale physical analogues with water. This article outlines each of these techniques in a non-technical manner, suitable for a clinical readership without specialist airflow or engineering knowledge.

CFD simulation of airborne pathogen transport due to human activities.

Computational Fluid Dynamics (CFD) is an increasingly popular tool for studying the impact of design interventions on the transport of infectious microorganisms. While much of the focus is on respiratory infections, there is substantial evidence that certain pathogens, such as those which colonise the skin, can be released into, and transported through the air through routine activities. In these situations the bacteria is released over a volume of space, with different intensities and locations varying in time rather than being released at a single point. This paper considers the application of CFD modelling to the evaluation of risk from this type of bioaerosol generation. An experimental validation study provides a direct comparison between CFD simulations and bioaerosol distribution, showing that passive scalar and particle tracking approaches are both appropriate for small particle bioaerosols. The study introduces a zonal source, which aims to represent the time averaged release of bacteria from an activity within a zone around the entire location the release takes place. This approach is shown to perform well when validated numerically though comparison with the time averaged dispersion patterns from a transient source. However, the ability of a point source to represent such dispersion is dependent on airflow regime. The applicability of the model is demonstrated using a simulation of an isolation room representing the release of bacteria from bedmaking.

Modelling the transmission of airborne infections in enclosed spaces.

The Wells-Riley equation for modelling airborne infection in indoor environments is incorporated into an SEIR epidemic model with a short incubation period to simulate the transmission dynamics of airborne infectious diseases in ventilated rooms. The model enables the effect of environmental factors such as the ventilation rate and the room occupancy to be examined, and allows the long-term impact of infection control measures to be assessed. A theoretical parametric study is carried out to demonstrate how changes to both the physical environment and infection control procedures may potentially limit the spread of short-incubation-period airborne infections in indoor environments such as hospitals.

The transmission of tuberculosis in confined spaces: an analytical review of alternative epidemiological models.

Tuberculosis (TB) is a disease that is closely associated with poverty, with transmission occurring in situations where infected persons are in close contact with others in confined spaces. While it is well recognised that overcrowding increases the risk of transmission, this increased risk has not been quantified and the relationship between overcrowding and duration of exposure is not well understood. This paper analyses three epidemiological models that have been used to predict the transmission of airborne disease in confined spaces: the Mass Action model, Riley, Murphy and Riley's model and Gammaitoni and Nucci's model. A study is presented to demonstrate the range of applicability of each model and show how they can be applied to the transmission of both TB and diseases with short incubation periods such as measles. Gammiatoni and Nucci's generalised formulation is shown to be the most suitable for modelling airborne transmission in ventilated spaces, and it is subsequently used in a parametric study to evaluate the effect of physical and environmental factors on the rate of disease transmission. The paper also presents reported quanta production data for several TB outbreaks and demonstrates that the greatest risk of TB infection is during clinical procedures that produce large quantities of aerosol, such as bronchoscopy or intubation.