Role of ventilation in airborne transmission of infectious agents in the built environment - a multidisciplinary systematic review

Rhinitis, asthma and respiratory infections among adults in relation to the home environment in multi-family buildings in Sweden

Risk factors for rhinitis, asthma and respiratory infections in the home environment were studied by a questionnaire survey. Totally 5775 occupants (≥ 18 years old) from a stratified random sample of multi-family buildings in Sweden participated (46%). 51.0% had rhinitis in the last 3 months (current rhinitis); 11.5% doctor diagnosed asthma; 46.4% respiratory infections in the last 3 months and 11.9% antibiotic medication for respiratory infections in the last 12 months. Associations between home environment and health were analyzed by multiple logistic regression, controlling for gender, age and smoking and mutual adjustment. Buildings constructed during 1960-1975 were risk factors for day time breathlessness (OR = 1.53, 95%CI 1.03-2.29). And those constructed during 1976-1985 had more current rhinitis (OR = 1.43, 95%CI 1.12-1.84) and respiratory infections (OR = 1.46, 95%CI 1.21-1.78). Cities with higher population density had more current rhinitis (p = 0.008) and respiratory infections (p<0.001). Rented apartments had more current rhinitis (OR = 1.23, 95%CI 1.07-1.40), wheeze (OR = 1.20, 95%CI 1.02-1.41), day time breathlessness (OR = 1.31, 95%CI 1.04-1.66) and respiratory infections (OR = 1.13, 95%CI 1.01-1.26). Living in colder parts of the country was a risk factor for wheeze (p = 0.03) and night time breathlessness (p = 0.002). Building dampness was a risk factor for wheeze (OR = 1.42, 95%CI 1.08-1.86) and day time breathlessness (OR = 1.57, 95%CI 1.09-2.27). Building dampness was a risk factor for health among those below 66 years old. Odor at home was a risk factor for doctor diagnosed asthma (OR = 1.49, 95%CI 1.08-2.06) and current asthma (OR = 1.52, 95%CI 1.03-2.24). Environmental tobacco smoke (ETS) was a risk factor for current asthma (OR = 1.53, 95%CI 1.09-2.16). Window panel condensation was a risk factor for antibiotic medication for respiratory infections (OR = 1.41, 95%CI 1.10-1.82). In conclusion, rhinitis, asthma and respiratory infections were related to a number of factors in the home environment. Certain building years (1961-1985), building dampness, window panel condensation and odor in the dwelling may be risk factors.

Identification of indoor contaminant source location by a single concentration sensor

Methods of maximum correlation coefficient (MCC) and the minimum discrete degree (MDD) are developed to identify the location of indoor contaminant source. These two methods are simple, effective, and economic due to the need of only one sensor. The methods are validated by a three-dimensional case study. The effects of the sampling time, the sampling interval, and the sensor response time and measurement error on the location identification of the contaminant source are analyzed. The results indicate that the identification performance of the MDD method is better than that of the MCC method; however, the MDD requires a fast response and high-accuracy sensor. MCC method not only has smaller effects of response time and measurement error compared with the MDD method but it also does not require high-performance (accuracy) sensor and it is not suitable for fast identification in a short time. For source location identification, the two methods need to properly choose sampling time, sampling interval, and response time.

The influence of human walking on the flow and airborne transmission in a six-bed isolation room: Tracer gas simulation

By performing unsteady CFD simulations using RNG k-ɛ model and dynamic mesh technique, this paper investigates how the walking motion of health care worker (HCW) influences gaseous dispersion in a six-bed isolation room with nine downward supplies and six ceiling-level or floor-level exhausts. The flow near and behind HCW is easily affected by HCW motion. The flow disturbance induced by HCW walking with swinging arms and legs is a mixing process. The walking HCW displaces air in front of it and carries air in the wake forwardly, meanwhile pressure difference drives air from two lateral sides into the wake. HCW motion (0-5.4 s) indeed induces a little gaseous dispersion, but the residual flow disturbance after HCW stops (5.4 s-25.4 s) induces more gaseous agent spread and it requires more than 30-60 s to approximately recover to the initial state after HCW stops. Although HCW motion indeed affects airborne transmission, but its effect is less important than ventilation design. No matter with or without HCW motion, the ceiling-level exhausts perform much better in controlling airborne transmission than the floor-level exhausts with the same air change rate (12.9 ACH). Smaller air change rate of 6 ACH experiences higher concentration and more gaseous spread than 12.9 ACH. In contrast to the realistic human walking, the simplified motion of a rectangular block produces stronger flow disturbance. Finally surface heating of HCW produces a stronger thermal body plume and enhances turbulence near HCW, thus slightly strengthens airborne transmission.

Viability of Pseudomonas aeruginosa in cough aerosols generated by persons with cystic fibrosis

Background

Person-to-person transmission of respiratory pathogens, including Pseudomonas aeruginosa, is a challenge facing many cystic fibrosis (CF) centres. Viable P aeruginosa are contained in aerosols produced during coughing, raising the possibility of airborne transmission.

Methods

Using purpose-built equipment, we measured viable P aeruginosa in cough aerosols at 1, 2 and 4 m from the subject (distance) and after allowing aerosols to age for 5, 15 and 45 min in a slowly rotating drum to minimise gravitational settling and inertial impaction (duration). Aerosol particles were captured and sized employing an Anderson Impactor and cultured using conventional microbiology. Sputum was also cultured and lung function and respiratory muscle strength measured.

Results

Nineteen patients with CF, mean age 25.8 (SD 9.2) years, chronically infected with P aeruginosa, and 10 healthy controls, 26.5 (8.7) years, participated. Viable P aeruginosa were detected in cough aerosols from all patients with CF, but not from controls; travelling 4 m in 17/18 (94%) and persisting for 45 min in 14/18 (78%) of the CF group. Marked inter-subject heterogeneity of P aeruginosa aerosol colony counts was seen and correlated strongly (r=0.73–0.90) with sputum bacterial loads. Modelling decay of viable P aeruginosa in a clinic room suggested that at the recommended ventilation rate of two air changes per hour almost 50 min were required for 90% to be removed after an infected patient left the room.

Conclusions

Viable P aeruginosa in cough aerosols travel further and last longer than recognised previously, providing additional evidence of airborne transmission between patients with CF.

Household air quality risk factors associated with childhood pneumonia in urban Dhaka, Bangladesh

To inform interventions to reduce the high burden of pneumonia in urban settings such as Kamalapur, Bangladesh, we evaluated household air quality risk factors for radiographically confirmed pneumonia in children. In 2009-2010, we recruited children < 5 years of age with pneumonia and controls from a population-based surveillance for respiratory and febrile illnesses. Piped natural gas was used by 85% of 331 case and 91% of 663 control households. Crowding, a tin roof in the living space, low socioeconomic status, and male sex of the child were risk factors for pneumonia. The living space in case households was 28% less likely than in control households to be cross-ventilated. Particulate matter concentrations were not significantly associated with pneumonia. With increasing urbanization and supply of improved cooking fuels to urban areas, the high burden of respiratory illnesses in urban populations such as Kamalapur may be reduced by decreasing crowding and improving ventilation in living spaces.

Ambient temperature and respiratory virus infection

Respiratory viruses are important pediatric pathogens with pronounced seasonal patterns of circulation. Various hypotheses have been put forth to explain the seasonality of these infections, many involving environmental factors. This review summarizes the effect of temperature on the epidemicity of respiratory viruses, with an emphasis on epidemiological findings from large-scale metanalyses, laboratory-derived data using animal models and possible mechanisms to account for viral seasonality.

Indoor airborne bacterial communities are influenced by ventilation, occupancy, and outdoor air source

Architects and engineers are beginning to consider a new dimension of indoor air: the structure and composition of airborne microbial communities. A first step in this emerging field is to understand the forces that shape the diversity of bioaerosols across space and time within the built environment. In an effort to elucidate the relative influences of three likely drivers of indoor bioaerosol diversity - variation in outdoor bioaerosols, ventilation strategy, and occupancy load - we conducted an intensive temporal study of indoor airborne bacterial communities in a high-traffic university building with a hybrid HVAC (mechanically and naturally ventilated) system. Indoor air communities closely tracked outdoor air communities, but human-associated bacterial genera were more than twice as abundant in indoor air compared with outdoor air. Ventilation had a demonstrated effect on indoor airborne bacterial community composition; changes in outdoor air communities were detected inside following a time lag associated with differing ventilation strategies relevant to modern building design. Our results indicate that both occupancy patterns and ventilation strategies are important for understanding airborne microbial community dynamics in the built environment.

Predicting transient particle transport in enclosed environments with the combined computational fluid dynamics and Markov chain method

To quickly obtain information about airborne infectious disease transmission in enclosed environments is critical in reducing the infection risk to the occupants. This study developed a combined computational fluid dynamics (CFD) and Markov chain method for quickly predicting transient particle transport in enclosed environments. The method first calculated a transition probability matrix using CFD simulations. Next, the Markov chain technique was applied to calculate the transient particle concentration distributions. This investigation used three cases, particle transport in an isothermal clean room, an office with an underfloor air distribution system, and the first-class cabin of an MD-82 airliner, to validate the combined CFD and Markov chain method. The general trends of the particle concentrations vs. time predicted by the Markov chain method agreed with the CFD simulations for these cases. The proposed Markov chain method can provide faster-than-real-time information about particle transport in enclosed environments. Furthermore, for a fixed airflow field, when the source location is changed, the Markov chain method can be used to avoid recalculation of the particle transport equation and thus reduce computing costs.

Noninvasive Mechanical Ventilation: Models to Assess Air and Particle Dispersion

Respiratory failure is a major complication of viral infections such as severe acute respiratory syndrome (SARS) [1], avian influenza H5N1 infection [2], and the 2009 pandemic influenza (H1N1) infection [3]. The course may progress rapidly to acute respiratory distress syndrome (ARDS) and multi-organ failure, requiring intensive care. Noninvasive ventilation (NIV) may play a supportive role in patients with severe viral pneumonia and early ARDS/acute lung injury. It can act as a bridge to invasive mechanical ventilation, although it is contraindicated in critically ill patients with hemodynamic instability and multi-organ dysfunction syndrome [4]. Transmission of some of these viral infections can convert from droplets to airborne during respiratory therapy.

Quantifying uncertainty in health impact assessment: a case-study example on indoor housing ventilation

Quantitative health impact assessment (HIA) is increasingly being used to assess the health impacts attributable to an environmental policy or intervention. As a consequence, there is a need to assess uncertainties in the assessments because of the uncertainty in the HIA models. In this paper, a framework is developed to quantify the uncertainty in the health impacts of environmental interventions and is applied to evaluate the impacts of poor housing ventilation. The paper describes the development of the framework through three steps: (i) selecting the relevant exposure metric and quantifying the evidence of potential health effects of the exposure; (ii) estimating the size of the population affected by the exposure and selecting the associated outcome measure; (iii) quantifying the health impact and its uncertainty. The framework introduces a novel application for the propagation of uncertainty in HIA, based on fuzzy set theory. Fuzzy sets are used to propagate parametric uncertainty in a non-probabilistic space and are applied to calculate the uncertainty in the morbidity burdens associated with three indoor ventilation exposure scenarios: poor, fair and adequate. The case-study example demonstrates how the framework can be used in practice, to quantify the uncertainty in health impact assessment where there is insufficient information to carry out a probabilistic uncertainty analysis.

Infectious Diseases

The objectives of this chapter are to provide a brief understanding of the following:1.

Clinical evaluation of infectious diseases and altered immune disorders, including physical examination and laboratory studies

2.

Various infectious disease processes, including etiology, pathogenesis, clinical presentation, and management

3.

Commonly encountered altered immune disorders, including etiology, clinical presentation, and management

4.

Precautions and guidelines that a physical therapist should implement when treating a patient with an infectious disease process or altered immunity

Risk of tuberculosis in high-rise and high density dwellings: an exploratory spatial analysis

Studies have shown that socioeconomic and environmental factors have direct/indirect influences on TB. This research focuses on TB prevalence of Hong Kong in relation to its compact urban development comprising of high-rise and high-density residential dwellings caused by rapid population growth and limited land resources. It has been postulated that occupants living on higher levels of a building would benefit from better ventilation and direct sunlight and thus less likely to contract infectious respiratory diseases. On the contrary, those on lower floors amid the dense clusters of high-rises are more susceptible to TB infection because of poorer air quality from street-level pollution and lesser exposure to direct sunlight. However, there have not been published studies to support these claims. As TB continues to threaten public health in Hong Kong, this study seeks to understand the effects of housing development on TB occurrences in an urban setting.

Association of classroom ventilation with reduced illness absence: a prospective study in California elementary schools

Limited evidence associates inadequate classroom ventilation rates (VRs) with increased illness absence (IA). We investigated relationships between VRs and IA in California elementary schools over two school years in 162 3rd-5th-grade classrooms in 28 schools in three school districts: South Coast (SC), Bay Area (BA), and Central Valley (CV). We estimated relationships between daily IA and VR (estimated from two year daily real-time carbon dioxide in each classroom) in zero-inflated negative binomial models. We also compared IA benefits and energy costs of increased VRs. All school districts had median VRs below the 7.1 l/s-person California standard. For each additional 1 l/s-person of VR, IA was reduced significantly (p<0.05) in models for combined districts (-1.6%) and for SC (-1.2%), and nonsignificantly for districts providing less data: BA (-1.5%) and CV (-1.0%). Assuming associations were causal and generalizable, increasing classroom VRs from the California average (4 l/s-person) to the State standard would decrease IA by 3.4%, increase attendance-linked funding to schools by $33 million annually, and increase costs by only $4 million. Further increasing VRs would provide additional benefits. These findings, while requiring confirmation, suggest that increasing classroom VRs above the State standard would substantially decrease illness absence and produce economic benefits.

HVAC filtration for controlling infectious airborne disease transmission in indoor environments: Predicting risk reductions and operational costs

This work describes and applies a methodology for estimating the impact of recirculating heating, ventilating, and air-conditioning (HVAC) particle filters on the control of size-resolved infectious aerosols in indoor environments using a modified version of the Wells-Riley model for predicting risks of infectious disease transmission. Estimates of risk reductions and associated operational costs of both HVAC filtration and equivalent outdoor air ventilation are modeled and compared using a case study of airborne transmission of influenza in a hypothetical office space. Overall, recirculating HVAC filtration was predicted to achieve risk reductions at lower costs of operation than equivalent levels of outdoor air ventilation, particularly for MERV 13-16 filters. Medium efficiency filtration products (MERV 7-11) are also inexpensive to operate but appear less effective in reducing infectious disease risks.

Role of QuantiFERON-TB-Gold In Tube assay for active and latent tuberculosis infection in investigation of tuberculosis outbreak in a university

BACKGROUND

Identification and monitoring of active tuberculosis (TB) and latent tuberculosis infection (LTBI) are the key steps to prevent transmission during a TB outbreak. The aim of this study was to evaluate the role of QuantiFERON-TB-Gold In Tube assay (QFT-GIT) in the investigation of active TB and LTBI cases during a TB outbreak in a university.

METHODS

In this study, enrolled students and teachers were evaluated with chest radiograph, questionnaire, and QFT-GIT test. The diagnosis of active pulmonary TB was based on sputum studies and chest radiographs. The questionnaire, which covered demographic information, underlying diseases, and environmental exposures, was applied to assess the association of risk factors by multiple logistic regressions.

RESULTS

A total of 159 participants completed the study protocol. Positive QFT-GIT results were demonstrated in class A (75.7%; 25/33), class B (57.1%; 20/35), and class C (37.5%; 3/8) in institute 1; class D (17.3%; 8/46) in institute 2; and class E (3.1%; 1/32) in institute 3; but none among the (0/5) administrative officers, who comprised the control group. "Number of contact with active TB cases" was strongly associated and correlated with the prediction of a positive QFT-GIT result in multivariate analysis (odds ratio = 1.99; 95% confidence interval, 1.52-2.61; p < 0.0001). Seven cases progressed to active TB infection, all showing positive QFT-GIT results (100%; 7/7).

CONCLUSION

Inclusion of QFT-GIT may be helpful in controlling and monitoring of active TB and LTBI cases during an investigation of a TB outbreak. The finding demonstrated that the QFT-GIT test was useful in accurately identifying infected and uninfected students, permitting rapid intervention.

Health benefits of particle filtration

The evidence of health benefits of particle filtration in homes and commercial buildings is reviewed. Prior reviews of papers published before 2000 are summarized. The results of 16 more recent intervention studies are compiled and analyzed. Also, reviewed are four studies that modeled health benefits of using filtration to reduce indoor exposures to particles from outdoors. Prior reviews generally concluded that particle filtration is, at best, a source of small improvements in allergy and asthma health effects; however, many early studies had weak designs. A majority of recent intervention studies employed strong designs and more of these studies report statistically significant improvements in health symptoms or objective health outcomes, particularly for subjects with allergies or asthma. The percentage improvement in health outcomes is typically modest, for example, 7% to 25%. Delivery of filtered air to the breathing zone of sleeping allergic or asthmatic persons may be more consistently effective in improving health than room air filtration. Notable are two studies that report statistically significant improvements, with filtration, in markers that predict future adverse coronary events. From modeling, the largest potential benefits of indoor particle filtration may be reductions in morbidity and mortality from reducing indoor exposures to particles from outdoor air.

Roles of sunlight and natural ventilation for controlling infection: historical and current perspectives

BACKGROUND

Infections caught in buildings are a major global cause of sickness and mortality. Understanding how infections spread is pivotal to public health yet current knowledge of indoor transmission remains poor.

AIM

To review the roles of natural ventilation and sunlight for controlling infection within healthcare environments.

METHODS

Comprehensive literature search was performed, using electronic and library databases to retrieve English language papers combining infection; risk; pathogen; and mention of ventilation; fresh air; and sunlight. Foreign language articles with English translation were included, with no limit imposed on publication date.

FINDINGS

In the past, hospitals were designed with south-facing glazing, cross-ventilation and high ceilings because fresh air and sunlight were thought to reduce infection risk. Historical and recent studies suggest that natural ventilation offers protection from transmission of airborne pathogens. Particle size, dispersal characteristics and transmission risk require more work to justify infection control practices concerning airborne pathogens. Sunlight boosts resistance to infection, with older studies suggesting potential roles for surface decontamination.

CONCLUSIONS

Current knowledge of indoor transmission of pathogens is inadequate, partly due to lack of agreed definitions for particle types and mechanisms of spread. There is recent evidence to support historical data on the effects of natural ventilation but virtually none for sunlight. Modern practice of designing healthcare buildings for comfort favours pathogen persistence. As the number of effective antimicrobial agents declines, further work is required to clarify absolute risks from airborne pathogens along with any potential benefits from additional fresh air and sunlight.

A hybrid model for investigating transient particle transport in enclosed environments

It is important to accurately model person-to-person particle transport in mechanical ventilation spaces to create and maintain a healthy indoor environment. The present study introduces a hybrid DES-Lagrangian and RANS-Eulerian model for simulating transient particle transport in enclosed environments; this hybrid model can ensure the accuracy and reduce the computing cost. Our study estimated two key time constants for the model that are important parameters for reducing the computing costs. The two time constants estimated were verified by airflow data from both an office and an aircraft cabin case. This study also conducted experiments in the first-class cabin of an MD-82 commercial airliner with heated manikins to validate the hybrid model. A pulse particle source was applied at the mouth of an index manikin to simulate a cough. The particle concentrations versus time were measured at the breathing zone of the other manikins. The trend of particle concentrations versus time predicted by the hybrid model agrees with the experimental data. Therefore, the proposed hybrid model can be used for investigating transient particle transport in enclosed environments.

The risk of airborne cross-infection in a room with vertical low-velocity ventilation

Downward flow ventilation systems are one of the most recommended ventilation strategies when contaminants in rooms must be removed and people must be protected from the risk of airborne cross-infection. This study is based on experimental tests carried out in a room with downward flow ventilation. Two breathing thermal manikins are placed in a room face to face. One manikin's breathing is considered to be the contaminated source to simulate a risky situation with airborne cross-infection. The position of the manikins in relation to the diffuser and the location of diffuser in the room as well as the distance between the manikins are being changed to observe the influence of these factors on the personal exposure of the target manikin. The results show that the DWF in different situations often is unable to penetrate the microenvironment generated by the manikins. The downward ventilation system can give an unexpected high level of contaminant exposure of the target manikin, when the distance between the manikins is reduced.

PRACTICAL IMPLICATIONS

Several guidelines recommend the downward ventilation system to reduce the risk of cross-infection between people in hospital rooms. This study shows that this recommendation should be taken into careful consideration. It is important to be aware of people position, position to other thermal loads in the room, and especially be aware of the distance between people if the exposure to the exhaled contaminants wants to be reduced.

Minimizing the exposure of airborne pathogens by upper-room ultraviolet germicidal irradiation: an experimental and numerical study

There has been increasing interest in the use of upper-room ultraviolet germicidal irradiation (UVGI) because of its proven effectiveness in disinfecting airborne pathogens. An improved drift flux mathematical model is developed for optimizing the design of indoor upper-room UVGI systems by predicting the distribution and inactivation of bioaerosols in a ventilation room equipped with a UVGI system. The model takes into account several bacteria removal mechanisms such as convection, turbulent diffusion, deposition and UV inactivation. Before applying the model, the natural die-off rate and susceptibility constants of bioaerosols were measured experimentally. Two bacteria aerosols, Escherichia coli and Serratia marcescens, were tested for this purpose. It was found out that the general decay trend of the bioaerosol concentration predicted by the numerical model agrees well with the experimental measurements. The modelling results agree better with experimental observations for the case when the UVGI inactivation mechanism dominates at the upper-room region than for the case without UVGI. The numerical results also illustrate that the spatial distribution of airborne bacteria was influenced by both air-flow pattern and irradiance distribution. In addition to predicting the local variation of concentration, the model assesses the overall performance of an upper-room UVGI system. This model has great potential for optimizing the design of indoor an upper-room UVGI systems.

A mouse model for the study of contact-dependent transmission of influenza A virus and the factors that govern transmissibility

Influenza A virus transmission by direct contact is not well characterized. Here, we describe a mouse model for investigation of factors regulating contact-dependent transmission. Strains within the H3N2 but not H1N1 subtype of influenza virus were transmissible, and reverse-engineered viruses representing hybrids of these subtypes showed that the viral hemagglutinin is a determinant of the transmissible phenotype. Transmission to contact mice occurred within the first 6 to 54 h after cohousing with directly infected index mice, and the proportion of contacts infected within this period was reduced if the index mice had been preinfected with a heterologous subtype virus. A threshold level of virus present in the saliva of the index mice was identified, above which the likelihood of transmission was greatly increased. There was no correlation with transmission and viral loads in the nose or lung. This model could be useful for preclinical evaluation of antiviral and vaccine efficacy in combating contact-dependent transmission of influenza.

Architectural design influences the diversity and structure of the built environment microbiome

Buildings are complex ecosystems that house trillions of microorganisms interacting with each other, with humans and with their environment. Understanding the ecological and evolutionary processes that determine the diversity and composition of the built environment microbiome--the community of microorganisms that live indoors--is important for understanding the relationship between building design, biodiversity and human health. In this study, we used high-throughput sequencing of the bacterial 16S rRNA gene to quantify relationships between building attributes and airborne bacterial communities at a health-care facility. We quantified airborne bacterial community structure and environmental conditions in patient rooms exposed to mechanical or window ventilation and in outdoor air. The phylogenetic diversity of airborne bacterial communities was lower indoors than outdoors, and mechanically ventilated rooms contained less diverse microbial communities than did window-ventilated rooms. Bacterial communities in indoor environments contained many taxa that are absent or rare outdoors, including taxa closely related to potential human pathogens. Building attributes, specifically the source of ventilation air, airflow rates, relative humidity and temperature, were correlated with the diversity and composition of indoor bacterial communities. The relative abundance of bacteria closely related to human pathogens was higher indoors than outdoors, and higher in rooms with lower airflow rates and lower relative humidity. The observed relationship between building design and airborne bacterial diversity suggests that we can manage indoor environments, altering through building design and operation the community of microbial species that potentially colonize the human microbiome during our time indoors.

A numerical study of bend-induced particle deposition in and behind duct bends

This paper investigated the microparticle deposition and distribution due to the presence of duct bends by employing the Eulerian approach with Reynolds stress turbulent model and a Lagrangian trajectory method. The air velocity, particle velocity and particle deposition velocity were validated with available experimental data. Several particle deposition ratios were proposed to describe the particle accumulation due to bends. Particle deposition velocities in and behind bends were analyzed numerically. It is found that bend walls with surfaces of higher capture velocity tend to accumulate more contaminant particles as seen with an increased factor of 1.2 times on particle deposition velocity. Particle deposition reaches a maximum value near bend outlet, e.g. 15.2 times deposition ratio for particles of d _p  = 23 μm, and decay exponentially to a status of fully developed deposition in approximately 10D length. Compared to traditional consideration of sole deposition in bends, a new general concept of total deposition including that in bends and behind bends is proposed to better describe the particle deposition induced by bends since the enhancement deposition ratios behind bends compose 42-99% in the total ratios for particles of d _p  = 3-23 μm. Furthermore, models of fast power and exponential decay trend are demonstrated to uncover the relationship among enhancement factor of deposition velocity behind bend, dimensionless distance behind bends and particle Stokes number. The present study can contribute to the understanding and controlling of contaminant aerosol flow behavior in ducts, e.g. particle sampling, removal and associated epidemiologic study between particle and human health.

Effectiveness of facemasks to reduce exposure hazards for airborne infections among general populations

Facemasks are widely used as a protective measure by general public to prevent inhalation of airborne pathogens including seasonal, swine and other forms of influenza and severe acute respiratory syndrome (SARS), etc. However, scientific data on effectiveness of facemasks in reducing infections in the community are extremely limited and even inconsistent. In this work, two manikins labelled as 'source' and 'susceptible' were used to measure the protection provided by facemasks under various emission scenarios. The source was modified to generate polydisperse ultrafine particles, whereas the susceptible was modified to mimic a realistic breathing pattern. The facemask was challenged by both pseudo-steady and highly transient emissions generated by an expiratory process where parameters, such as separation distance between manikins, emission velocity and expiratory duration, were controlled and measured systematically. Performances of four different types of facemask fits, varying from ideal to normal wearing practice, were also investigated. Under the pseudo-steady concentration environment, facemask protection was found to be 45 per cent, while under expiratory emissions, protection varied from 33 to 100 per cent. It was also observed that the separation between the source and the manikin was the most influential parameter affecting facemask protection.

Human occupancy as a source of indoor airborne bacteria

Exposure to specific airborne bacteria indoors is linked to infectious and noninfectious adverse health outcomes. However, the sources and origins of bacteria suspended in indoor air are not well understood. This study presents evidence for elevated concentrations of indoor airborne bacteria due to human occupancy, and investigates the sources of these bacteria. Samples were collected in a university classroom while occupied and when vacant. The total particle mass concentration, bacterial genome concentration, and bacterial phylogenetic populations were characterized in indoor, outdoor, and ventilation duct supply air, as well as in the dust of ventilation system filters and in floor dust. Occupancy increased the total aerosol mass and bacterial genome concentration in indoor air PM(10) and PM(2.5) size fractions, with an increase of nearly two orders of magnitude in airborne bacterial genome concentration in PM(10). On a per mass basis, floor dust was enriched in bacterial genomes compared to airborne particles. Quantitative comparisons between bacterial populations in indoor air and potential sources suggest that resuspended floor dust is an important contributor to bacterial aerosol populations during occupancy. Experiments that controlled for resuspension from the floor implies that direct human shedding may also significantly impact the concentration of indoor airborne particles. The high content of bacteria specific to the skin, nostrils, and hair of humans found in indoor air and in floor dust indicates that floors are an important reservoir of human-associated bacteria, and that the direct particle shedding of desquamated skin cells and their subsequent resuspension strongly influenced the airborne bacteria population structure in this human-occupied environment. Inhalation exposure to microbes shed by other current or previous human occupants may occur in communal indoor environments.

Cooking fuel type, household ventilation, and the risk of acute lower respiratory illness in urban Bangladeshi children: a longitudinal study

Acute lower respiratory illnesses (ALRI) are the leading cause of death among children <5 years. Studies have found that biomass cooking fuels are an important risk factor for ALRI. However, few studies have evaluated the influence of natural household ventilation indicators on ALRI. The purpose of this study was to assess the association between cooking fuel, natural household ventilation, and ALRI. During October 17, 2004-September 30, 2005, children <5 years living in a low-income neighborhood of Dhaka, Bangladesh, were assessed weekly for ALRI and surveyed quarterly about biomass fuel use, electric fan ownership, and natural household ventilation (windows, ventilation grates, and presence of a gap between the wall and ceiling). Bivariate and multivariate analyses were performed using generalized estimating equations. Six thousand and seventy-nine children <5 years enrolled during the study period (99% participation) experienced 1291 ALRI. In the multivariate model, ≥2 windows [OR = 0.75, 95% CI = (0.58, 0.96)], ventilation grates [OR = 0.80, 95% CI = (0.65, 0.98)], and not owning an electric fan [OR = 1.50, 95% CI = (1.21, 1.88)] were associated with ALRI; gap presence and using biomass fuels were not associated with ALRI. Structural factors that might improve household air circulation and exchange were associated with decreased ALRI risk. Improved natural ventilation might reduce ALRI among children in low-income families.

PRACTICAL IMPLICATIONS

The World Health Organization has stated that controlling pneumonia is a priority for achieving the fourth Millennium Development Goal, which calls for a two-third reduction in mortality of children <5 years old compared to the 1990 baseline. Our study represents an important finding of a modifiable risk factor that might decrease the burden of respiratory illness among children living in Bangladesh and other low-income settings similar to our study site. We found that the existence of at least two windows in the child's sleeping room was associated with a 25% decreased ALRI risk. Increasing available natural ventilation within the household in similar settings has the potential to reduce childhood mortality because of acute lower respiratory illnesses.

Spatial dynamics of airborne infectious diseases

Disease outbreaks, such as those of Severe Acute Respiratory Syndrome in 2003 and the 2009 pandemic A(H1N1) influenza, have highlighted the potential for airborne transmission in indoor environments. Respirable pathogen-carrying droplets provide a vector for the spatial spread of infection with droplet transport determined by diffusive and convective processes. An epidemiological model describing the spatial dynamics of disease transmission is presented. The effects of an ambient airflow, as an infection control, are incorporated leading to a delay equation, with droplet density dependent on the infectious density at a previous time. It is found that small droplets (∼0.4μm) generate a negligible infectious force due to the small viral load and the associated duration they require to transmit infection. In contrast, larger droplets (∼4μm) can lead to an infectious wave propagating through a fully susceptible population or a secondary infection outbreak for a localized susceptible population. Droplet diffusion is found to be an inefficient mode of droplet transport leading to minimal spatial spread of infection. A threshold air velocity is derived, above which disease transmission is impaired even when the basic reproduction number R(0) exceeds unity.

Characteristics of physical blocking on co-occupant's exposure to respiratory droplet residuals

Existed evidences show that airborne transmission of human respiratory droplets may be related with the spread of some infectious disease, such as severe acute respiratory syndrome (SARS) and H1N1 pandemic. Non-pharmaceutical approaches, including ventilation system and personal protection, are believed to have certain positive effects on the reduction of co-occupant's inhalation. This work then aims to numerically study the performances of mouth covering on co-occupant's exposure under mixing ventilation (MV), under-floor air distribution (UFAD) and displacement ventilation (DV) system, using drift-flux model. Desk partition, as one generally employed arrangement in plan office, is also investigated under MV. The dispersion of 1, 5 and 10 μm droplet residuals are numerically calculated and CO2 is used to represent tracer gas. The results show that using mouth covering by the infected person can reduce the co-occupant's inhalation greatly by interrupting direct spread of the expelled droplets, and best performance can be achieved under DV since the coughed air is mainly confined in the microenvironment of the infected person. The researches under MV show that the two interventions, mouth covering and desk partition, achieve almost the same inhalation for fine droplets while the inhalation of the co-occupant is lower when using mouth covering for large droplets.

Distribution of exhaled contaminants and personal exposure in a room using three different air distribution strategies

The level of exposure to human exhaled contaminants in a room depends not only on the air distribution system but also on people's different positions, the distance between them, people's activity level and height, direction of exhalation, and the surrounding temperature and temperature gradient. Human exhalation is studied in detail for different distribution systems: displacement and mixing ventilation as well as a system without mechanical ventilation. Two thermal manikins breathing through the mouth are used to simulate the exposure to human exhaled contaminants. The position and distance between the manikins are changed to study the influence on the level of exposure. The results show that the air exhaled by a manikin flows a longer distance with a higher concentration in case of displacement ventilation than in the other two cases, indicating a significant exposure to the contaminants for one person positioned in front of another. However, in all three cases, the exhalation flow of the source penetrates the thermal plume, causing an increase in the concentration of contaminants in front of the target person. The results are significantly dependent on the distance and position between the two manikins in all three cases.

PRACTICAL IMPLICATIONS

Indoor environments are susceptible to contaminant exposure, as contaminants can easily spread in the air. Human breathing is one of the most important biological contaminant sources, as the exhaled air can contain different pathogens such as viruses and bacteria. This paper addresses the human exhalation flow and its behavior in connection with different ventilation strategies, as well as the interaction between two people in a room. This is a key factor for studying the airborne infection risk when the room is occupied by several persons. The paper only takes into account the airborne part of the infection risk.

Dispersion and exposure to a cough-generated aerosol in a simulated medical examination room

Few studies have quantified the dispersion of potentially infectious bioaerosols produced by patients in the health care environment and the exposure of health care workers to these particles. Controlled studies are needed to assess the spread of bioaerosols and the efficacy of different types of respiratory personal protective equipment (PPE) in preventing airborne disease transmission. An environmental chamber was equipped to simulate a patient coughing aerosol particles into a medical examination room, and a health care worker breathing while exposed to these particles. The system has three main parts: (1) a coughing simulator that expels an aerosol-laden cough through a head form; (2) a breathing simulator with a second head form that can be fitted with respiratory PPE; and (3) aerosol particle counters to measure concentrations inside and outside the PPE and at locations throughout the room. Dispersion of aerosol particles with optical diameters from 0.3 to 7.5 μm was evaluated along with the influence of breathing rate, room ventilation, and the locations of the coughing and breathing simulators. Penetration of cough aerosol particles through nine models of surgical masks and respirators placed on the breathing simulator was measured at 32 and 85 L/min flow rates and compared with the results from a standard filter tester. Results show that cough-generated aerosol particles spread rapidly throughout the room, and that within 5 min, a worker anywhere in the room would be exposed to potentially hazardous aerosols. Aerosol exposure is highest with no personal protective equipment, followed by surgical masks, and the least exposure is seen with N95 FFRs. These differences are seen regardless of breathing rate and relative position of the coughing and breathing simulators. These results provide a better understanding of the exposure of workers to cough aerosols from patients and of the relative efficacy of different types of respiratory PPE, and they will assist investigators in providing research-based recommendations for effective respiratory protection strategies in health care settings.

Role of air changes per hour (ACH) in possible transmission of airborne infections

The cost of nosocomial infections in the United States is estimated to be $4 billion to $5 billion annually. Applying a scientifically based analysis to disease transmission and performing a site specific risk analysis to determine the design of the ventilation system can provide real and long term cost savings. Using a scientific approach and convincing data, this paper hypothetically illustrates how a ventilation system design can be optimized to potentially reduce infection risk to occupants in an isolation room based on a thorough risk assessment without necessarily increasing ventilation airflow rate. A computational fluid dynamics (CFD) analysis was performed to examine the transport mechanism, particle path and a suggested control strategy for reducing airborne infectious disease agents. Most studies on the transmission of infectious disease particles have concentrated primarily on air changes per hour (ACH) and how ACH provides a dilution factor for possible infectious agents. Although increasing ventilation airflow rate does dilute concentrations better when the contaminant source is constant, it does not increase ventilation effectiveness. Furthermore, an extensive literature review indicates that not every exposure to an infectious agent will necessarily cause a recipient infection. The results of this study suggest a hypothesis that in an enclosed and mechanically ventilated room (e.g., an isolation room), the dominant factor that affects the transmission and control of contaminants is the path between the contaminant source and exhaust. Contaminants are better controlled when this path is uninterrupted by an air stream. This study illustrates that the ventilation system design, i.e., when it conforms with the hypothesized path principle, may be a more important factor than flow rate (i.e., ACH). A secondary factor includes the distance from the contaminant source. This study provides evidence and supports previous studies that moving away from the patient generally reduces the infection risk in a transient (coughing) situation, although the effect is more pronounced under higher flow rate. It is noted that future research is needed to determine the exact mode of transmission for most recently identified organisms.

A home toolkit for primary prevention of influenza by individuals and families

An influenza pandemic can overwhelm the capacities of hospitals, clinics, nursing facilities, and emergency services. The likelihood is that most of the individuals who are stricken will be cared for at home, and there is strong evidence that in-home caregivers bear a disproportionate risk of becoming infected. We reviewed the scientific literature after 2000 to identify steps that in-home caregivers can take to reduce the chances that they and other household members will become infected in the home. Personal hygiene, common masks, and technologies including air filters and UV light each offer incremental benefits, and in combination are expected to reduce a portion of the risk that household members face when caring for a member who has become infected. In pandemics and even seasonal epidemics, seemingly small steps can literally mean the difference between life and death, especially for in-home caregivers.

Hospital ventilation simulation for the study of potential exposure to contaminants

Airflow and ventilation are particularly important in healthcare rooms for controlling thermo-hygrometric conditions, providing anaesthetic gas removal, diluting airborne bacterial contamination and minimizing bacteria transfer airborne. An actual hospitalization room was the investigate case study. Transient simulations with computational fluid dynamics (CFD), based on the finite element method (FEM) were performed to investigate the efficiency of the existing heating, ventilation and air-conditioning (HVAC) plant with a variable air volume (VAV) primary air system. Solid modelling of the room, taking into account thermo-physical properties of building materials, architectural features (e.g., window and wall orientation) and furnishing (e.g., beds, tables and lamps) arrangement of the room, inlet turbulence high induction air diffuser, the return air diffusers and two patients lying on two parallel beds was carried out. Multiphysics modelling was used: a thermo-fluidynamic model (convection-conduction and incompressible Navier-Stokes) was combined with a convection-diffusion model. Three 3D models were elaborated considering different conditions/events of the patients (i.e., the first was considered coughing and/or the second breathing). A particle tracing and diffusion model, connected to cough events, was developed to simulate the dispersal of bacteria-carrying droplets in the isolation room equipped with the existing ventilation system. An analysis of the region of droplet fallout and the dilution time of bacteria diffusion of coughed gas in the isolation room was performed. The analysis of transient simulation results concerning particle path and distance, and then particle tracing combined with their concentration, provided evidence of the formation of zones that should be checked by microclimatic and contaminant control. The present study highlights the fact that the CFD-FEM application is useful for understanding the efficiency, adequacy and reliability of the ventilation system, but also provides important suggestions for controlling air quality, patients' comfort and energy consumption in a hospital.

Room ventilation and the risk of airborne infection transmission in 3 health care settings within a large teaching hospital

BACKGROUND

Room ventilation is a key determinant of airborne disease transmission. Despite this, ventilation guidelines in hospitals are not founded on robust scientific evidence related to the prevention of airborne transmission.

METHODS

We sought to assess the effect of ventilation rates on influenza, tuberculosis, and rhinovirus infection risk within 3 distinct rooms in a major urban hospital: a lung function laboratory, an emergency department negative-pressure isolation room, and an outpatient consultation room. Air-exchange rate measurements were performed in each room using CO2 as a tracer. The model developed by Gammaitoni and Nucci was used to estimate infection risk.

RESULTS

Current outdoor air-exchange rates in the lung function laboratory and emergency department isolation room limited infection risks to 0.1%-3.6%. Influenza risk for individuals entering an outpatient consultation room after an infectious individual departed ranged from 3.6% to 20.7%, depending on the duration for which each person occupied the room.

CONCLUSION

Given the absence of definitive ventilation guidelines for hospitals, air-exchange measurements combined with modeling afford a useful means of assessing, on a case-by-case basis, the suitability of room ventilation for preventing airborne disease transmission.

In China, students in crowded dormitories with a low ventilation rate have more common colds: evidence for airborne transmission

Objective

To test whether the incidence of common colds among college students in China is associated with ventilation rates and crowdedness in dormitories.

Methods

In Phase I of the study, a cross-sectional study, 3712 students living in 1569 dorm rooms in 13 buildings responded to a questionnaire about incidence and duration of common colds in the previous 12 months. In Phase II, air temperature, relative humidity and CO₂ concentration were measured for 24 hours in 238 dorm rooms in 13 buildings, during both summer and winter. Out-to indoor air flow rates at night were calculated based on measured CO₂ concentrations.

Results

In Phase I, 10% of college students reported an incidence of more than 6 common colds in the previous 12 months, and 15% reported that each infection usually lasted for more than 2 weeks. Students in 6-person dorm rooms were about 2 times as likely to have an incidence of common colds ≥6 times per year and a duration ≥2 weeks, compared to students in 3-person rooms. In Phase II, 90% of the measured dorm rooms had an out-to indoor air flow rate less than the Chinese standard of 8.3 L/s per person during the heating season. There was a dose-response relationship between out-to indoor air flow rate per person in dorm rooms and the proportion of occupants with annual common cold infections ≥6 times. A mean ventilation rate of 5 L/(s•person) in dorm buildings was associated with 5% of self reported common cold ≥6 times, compared to 35% at 1 L/(s•person).

Conclusion

Crowded dormitories with low out-to indoor airflow rates are associated with more respiratory infections among college students.

Quantify impacted scope of human expired air under different head postures and varying exhalation rates

Many researches indicate human respiration flow and background ventilation are two important aspects leading to possible respiratory disease spread. However, current studies on respiration flow and the resulted exhaled pollutant dispersion are limited, because different head postures, respiration mode, breath rate, room ventilation and so on, can exert profound impacts that are not understood very clearly. To evaluate the role of head postures on transmission of human exhaled pollutants, this study uses a computational fluid dynamics (CFD) program to study the exhalation flow of a sitting adult in a calm indoor office. Four different head postures are considered: sitting upright viewing front, sitting upright but head tilted viewing upward, sitting upright but head turned viewing the lateral, and sitting but pillowing head on a table. Based on the decay percentage of a gas concentration, the impacted scope of expired air is identified. The common posture by sitting upright viewing front is selected to investigate the change of impacted scope with increasing exhalation rates. The experimental test is also carried out using a breathing thermal manikin. This study finds out that the impacted scope of expired air under different head postures is different. The horizontal impacted distance is highly dependent on the specified threshold concentration. If a person sits around at a table and makes a deep exhalation, other people shall be apart from him/her with a larger distance to be free from the exhaled pollutant exposure, once his/her thermal plume is blocked by the table.

Benefits and costs of improved IEQ in U.S. offices

This study estimates some of the benefits and costs of implementing scenarios that improve indoor environmental quality (IEQ) in the stock of U.S. office buildings. The scenarios include increasing ventilation rates when they are below 10 or 15 l/s per person, adding outdoor air economizers and controls when absent, eliminating winter indoor temperatures >23°C, and reducing dampness and mold problems. The estimated benefits of the scenarios analyzed are substantial in magnitude, including increased work performance, reduced Sick Building Syndrome symptoms, reduced absence, and improved thermal comfort for millions of office workers. The combined potential annual economic benefit of a set of nonoverlapping scenarios is approximately $20 billion. While the quantitative estimates have a high uncertainty, the opportunity for substantial benefits is clear. Some IEQ improvement measures will save energy while improving health or productivity, and implementing these measures should be the highest priority.

PRACTICAL IMPLICATIONS

Owners, designers, and operators of office buildings have an opportunity to improve IEQ, health, work performance, and comfort of building occupants and to obtain economic benefits by improving IEQ. These benefits can be achieved with simultaneous energy savings or with only small increases in energy costs.

An experimental study quantifying pulmonary ventilation on inhalation of aerosol under steady and episodic emission

Estimating inhalation dose accurately under realistic conditions can enhance the accuracy of risk assessment. Conventional methods to quantify aerosol concentration that susceptible victims in contaminated environments are exposed to use real time particle counters to measure concentrations in environments without occupancy. Breathing-induced airflow interacts and influences concentration around nostrils or mouth and alter the ultimate exposure. This subject has not yet been systematically studied, particularly under transient emission. In this work, an experimental facility comprising two manikins was designed and fabricated. One of them mimicked realistic breathing, acting as a susceptible victim. Both steady and episodic emissions were generated in an air-conditioned environmental chamber in which two different ventilation schemes were tested. The scaled-dose of the victim under different expiratory velocities and pulmonary ventilation was measured. Inferring from results obtained from comprehensive tests, it can be concluded that breathing has very significant influence on the ultimate dose compared with that without breathing. Majority of results show that breathing reduces inhalation quantity and the reduction magnitude increases with breathing rate. This is attributed to the fact that the exhalation process plays a more significant role in reducing the dose level than the enhanced effect during inhalation period. The higher the breathing rate, the sharper the decline of the resultant concentration would be leading to lower dose. Nevertheless, under low pulmonary ventilation, results show that breathing increases dose marginally. Results also reveals that ventilation scheme also affects the exposure.

Effect of enhanced ultraviolet germicidal irradiation in the heating ventilation and air conditioning system on ventilator-associated pneumonia in a neonatal intensive care unit

OBJECTIVE

The objective of this study was to test the hypothesis that enhanced ultraviolet germicidal irradiation (eUVGI) installed in our neonatal intensive care unit (NICU) heating ventilation and air conditioning system (HVAC) would decrease HVAC and NICU environment microbes, tracheal colonization and ventilator-associated pneumonia (VAP).

STUDY DESIGN

The study was designed as a prospective interventional pre- and post-single-center study. University-affiliated Regional Perinatal Center NICU. Intubated patients in the NICU were evaluated for colonization, and a high-risk sub-population of infants <30 weeks gestation ventilated for ≥ 14 days was studied for VAP. eUVGI was installed in the NICU's remote HVACs. The HVACs, NICU environment and intubated patients' tracheas were cultured pre- and post-eUVGI for 12 months. The high-risk patients were studied for VAP (positive bacterial tracheal culture, increased ventilator support, worsening chest radiograph and ≥ 7 days of antibiotics).

RESULT

Pseudomonas, Klebsiella, Serratia, Acinetobacter, Staphylococcus aureus and Coagulase-negative Staphylococcus species were cultured from all sites. eUVGI significantly decreased HVAC organisms (baseline 500,000 CFU cm(-2); P=0.015) and NICU environmental microbes (P<0.0001). Tracheal microbial loads decreased 45% (P=0.004), and fewer patients became colonized. VAP in the high-risk cohort fell from 74% (n=31) to 39% (n=18), P=0.04. VAP episodes per patient decreased (Control: 1.2 to eUVGI: 0.4; P=0.004), and antibiotic usage was 62% less (P=0.013).

CONCLUSION

eUVGI decreased HVAC microbial colonization and was associated with reduced NICU environment and tracheal microbial colonization. Significant reductions in VAP and antibiotic use were also associated with eUVGI in this single-center study. Large randomized multicenter trials are needed.

Critical review and uncertainty analysis of factors influencing influenza transmission

Influenza remains a significant threat to public health, yet there is significant uncertainty about the routes of influenza transmission from an infectious source through the environment to a receptor, and their relative risks. Herein, data pertaining to factors that influence the environmental mediation of influenza transmission are critically reviewed, including: frequency, magnitude and size distribution and virus expiration, inactivation rates, environmental and self-contact rates, and viral transfer efficiencies during contacts. Where appropriate, two-stage Monte Carlo uncertainty analysis is used to characterize variability and uncertainty in the reported data. Significant uncertainties are present in most factors, due to: limitations in instrumentation or study realism; lack of documentation of data variability; or lack of study. These analyses, and future experimental work, will improve parameterization of influenza transmission and risk models, facilitating more robust characterization of the magnitude and uncertainty in infection risk.