Isolation rooms for highly infectious diseases: an inventory of capabilities in European countries

Designing a new fast solution to control isolation rooms in hospitals depending on artificial intelligence decision

Decreasing the COVID spread of infection among patients at physical isolation hospitals during the coronavirus pandemic was the main aim of all governments in the world. It was required to increase isolation places in the hospital's rules to prevent the spread of infection. To deal with influxes of infected COVID-19 patients’ quick solutions must be explored. The presented paper studies converting natural rooms in hospitals into isolation sections and constructing new isolation cabinets using prefabricated components as alternative and quick solutions. Artificial Intelligence (AI) helps in the selection and making of a decision on which type of solution will be used. A Multi-Layer Perceptron Neural Network (MLPNN) model is a type of artificial intelligence technique used to design and implement on time, cost, available facilities, area, and spaces as input parameters. The MLPNN result decided to select a prefabricated approach since it saves 43% of the time while the cost was the same for the two approaches. Forty-five hospitals have implemented a prefabricated solution which gave excellent results in a short period of time at reduced costs based on found facilities and spaces. Prefabricated solutions provide a shorter time and lower cost by 43% and 78% in average values respectively as compared to retrofitting existing natural ventilation rooms.

Nipah Virus Disease: Recent Perspective and One Health Approach

Background

Nipah virus (NiV) first emerged in 1998 in Malaysia, causing an outbreak of respiratory illness and encephalitis in pigs. Pig-to-human transmission of NiV associated with severe febrile encephalitis was described, and it was thought to occur through close contact with infected animals. The first outbreak was reported in India in Siliguri, West Bengal in 2001 followed by Nadia, West Bengal and adjoining areas of Bangladesh in 2007, where an intermediate animal host was not identified, suggesting bat-to-human and human-to-human transmissions. Although it is extremely difficult to document the spillover event and ascertain crossing of trans-natural boundaries by bats and bringing new viruses in an unexposed population, efforts for source identification are important to understand the epidemiology of disease. As the disease transcends beyond one species and has shown to infect humans, it therefore requires the 'One Health approach' in which multiple sectors coordinate and work together to achieve better public health outcomes.

Objective

We summarize the re-emergence and response of the Nipah virus outbreaks (NiVD) in Kerala, India, about 1800 kms away, a decade later in 2018 and 2019. The paper recapitulates involvement of various stakeholders from the Ministry of Health and Family Welfare, Directorate of Health Research, Indian Council of Agricultural Research, State Health Department, State Animal Husbandry, District Administration, and multidisciplinary response mechanism during the NiVD outbreaks of 2018 and 2019.

Methods

Information was collected from the Press Information Bureau (PIB), media/weekly alerts from the Integrated Disease Surveillance Programme (IDSP), news articles from print and electronic media, newsletters, advisories from the National Centre for Disease Control (NCDC), Disease Outbreak News (DON), World Health Organization (WHO), and published papers from various stakeholders.

Findings & Conclusion

The evidence of NiV in humans and bats, with samples collected from the outbreak sites, was laboratory confirmed. The multidisciplinary response mechanisms during the 2018 outbreak helped in further understanding the importance of the One Health approach for systemic and streamlined response utilizing existing surveillance systems. This was of utmost help in the subsequent outbreak of the disease that occurred during 2019, wherein there was no documented spread of disease from the index case and no mortality was observed. This success reiterates the need for institutionalizing the involvement and cooperation of various departments and organizations during public health emergencies, especially of Zoonotic diseases, using the One Health approach.

Impact of isolation on hospitalised patients who are infectious: systematic review with meta-analysis

OBJECTIVE

To systematically review the literature exploring the impact of isolation on hospitalised patients who are infectious: psychological and non-psychological outcomes.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

Embase, Medline and PsycINFO were searched from inception until December 2018. Reference lists and Google Scholar were also handsearched.

RESULTS

Twenty-six papers published from database inception to December 2018 were reviewed. A wide range of psychological and non-psychological outcomes were reported. There was a marked trend for isolated patients to exhibit higher levels of depression, the pooled standardised mean difference being 1.28 (95% CI 0.47 to 2.09) and anxiety 1.45 (95% CI 0.56 to 2.34), although both had high levels of heterogeneity, and worse outcomes for a range of care-related factors but with significant variation.

CONCLUSION

The review indicates that isolation to contain the risk of infection has negative consequences for segregated patients. Although strength of the evidence is weak, comprising primarily single-centre convenience samples, consistency of the effects may strengthen this conclusion. More research needs to be undertaken to examine this relationship and develop and test interventions to reduce the negative effects of isolation.

Impact of isolation on hospitalised patients who are infectious: systematic review with meta-analysis

OBJECTIVE

To systematically review the literature exploring the impact of isolation on hospitalised patients who are infectious: psychological and non-psychological outcomes.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

Embase, Medline and PsycINFO were searched from inception until December 2018. Reference lists and Google Scholar were also handsearched.

RESULTS

Twenty-six papers published from database inception to December 2018 were reviewed. A wide range of psychological and non-psychological outcomes were reported. There was a marked trend for isolated patients to exhibit higher levels of depression, the pooled standardised mean difference being 1.28 (95% CI 0.47 to 2.09) and anxiety 1.45 (95% CI 0.56 to 2.34), although both had high levels of heterogeneity, and worse outcomes for a range of care-related factors but with significant variation.

CONCLUSION

The review indicates that isolation to contain the risk of infection has negative consequences for segregated patients. Although strength of the evidence is weak, comprising primarily single-centre convenience samples, consistency of the effects may strengthen this conclusion. More research needs to be undertaken to examine this relationship and develop and test interventions to reduce the negative effects of isolation.

Strict Isolation

Strict isolation: suspected highly infectious and transmissible virulent and pathogenic microbes, highly resistant bacterial strains and agents that are not accepted in any form of distribution in the society or in the environment. Examples are completely resistant Mycobacterium tuberculosis, viral haemorrhagic fevers like Ebola and Lassa, pandemic severe influenza and coronavirus like SARS, MERS, etc. In most countries, strict isolation is a rarely used isolation regime but should be a part of the national preparedness plan. For instance, in Norway, strict isolation has not been used for the last 50–60 years, except for one case of imported Ebola infection in 2014. Patients in need of strict isolation should be placed in a separate isolation ward or building.

Infection spread by contact, droplet and airborne infection, aerosols, re-aerosols, airborne microbe-carrying particles, skin cells, dust, droplets and droplet nuclei. At the same time, it is always contact transmission (contaminated environment, equipment, textiles and waste).

The source of infection is usually a patient but may also be a symptomless carrier or a zoonotic disease.

Background Information: Isolation Routines

The isolation of patients with suspected or documented infections—to not spread to others—has been discussed for hundreds of years. Guidelines are many, methods are different, attitudes show vide variations, routines and procedures are still changing, regulations by law may be absent, and some healthcare professionals may be afraid of adverse outcomes of isolation [1–44]. Microbes that are spread in the environment, on the hands and equipment are invisible. The invisible agent does not call on attention before the infection; clinical disease, hospital infection or nosocomial infection is a factum that can be registered [23, 28, 29, 35–37]. How to stop the transmission is often “to believe and not believe” in infection control.

Isolating infectious patients: organizational, clinical, and ethical issues

BACKGROUND

Isolating infectious patients is essential to reduce infection risk. Effectiveness depends on identifying infectious patients, transferring them to suitable accommodations, and maintaining precautions.

METHODS

Online study to address identification of infectious patients, transfer, and challenges of maintaining isolation in hospitals in the United Kingdom.

RESULTS

Forty-nine responses were obtained. Decision to isolate is made by infection prevention teams, clinicians, and managers. Respondents reported situations where isolation was impossible because of the patient's physical condition or cognitive status. Very sick patients and those with dementia were not thought to tolerate isolation well. Patients were informed about the need for isolation by ward nurses, sometimes with explanations from infection prevention teams. Explanations were often poorly received and comprehended, resulting in complaints. Respondents were aware of ethical dilemmas associated with isolation that is undertaken in the interests of other health service users and society. Organizational failures could delay initaiting isolation. Records were kept of the demand for isolation and/or uptake, but quality was variable.

CONCLUSION

Isolation has received the most attention in countries with under-provision of accommodations. Our study characterizes reasons for delays in identifying patients and failures of isolation, which place others at risk and which apply to any organization regardless of availability. It also highlights the ethical dilemmas of enforcing isolation.

Assessing the functionality of temporary isolation rooms

BACKGROUND

Challenges with limited single rooms and isolation facilities in hospitals have created an opportunity for temporary, portable isolation technology. This article describes the process used to evaluate the prototype of a new isolation room (RediRoom; CareStrategic Ltd, Brisbane, Queensland, Australia) that can be installed in existing hospital ward areas. Our aim is to assess the functionality of this new room, and in so doing, to evaluate the methods used.

METHODS

We employed a mixed-methods approach involving video recording, interviews, and objective temperature and humidity measurements within a crossover interventional study. Participants completed a range of clinical activities in the RediRoom and a control. The setting for the study was a clinical ward environment at an Australian higher education institution.

RESULTS

There were similarities between the RediRoom and the control using a range of measures. The time taken to complete a range of clinical activities in both rooms was broadly consistent. Network analysis also suggested broad similarities in the movement of nurses undertaking activities in both rooms.

CONCLUSION

Our study attempted to simulate a clinical environment and clinical activities and provide the best possible comparison by completing activities sequentially, with immediate feedback to researchers. Video recording added significant value to the process because it provided some objectivity. A form of reflexive ethnography with participants could be of value in similar studies in the future.

A gap analysis of the United States death care sector to determine training and education needs pertaining to highly infectious disease mitigation and management

PURPOSE

A United States industry-specific gap analysis survey of the death care sector-which comprises organizations and businesses affiliated with the funeral industry and the handling of human remains- was developed, the results analyzed, and training and education needs in relation to highly infectious disease mitigation and management were explored in an effort to identify where occupational health and safety can be enhanced in this worker population.

METHODS

Collaborating national death care organizations distributed the 47-question electronic survey. N = 424 surveys were initiated and results recorded. The survey collected death care sector-specific information pertaining to the comfortability and willingness to handle highly infectious remains; perceptions of readiness, current policies and procedures in place to address highly infectious diseases; current highly infectious disease training levels, available resources, and personal protective equipment.

RESULTS

One-third of respondents have been trained on how to manage highly infectious remains. There was a discrepancy between Supervisor/Management and Employee/Worker perceptions on employees' willingness and comfortability to manage potentially highly infectious remains. More than 40% of respondents did not know the correct routes of transmission for viral hemorrhagic fevers.

CONCLUSIONS

Results suggest death care workers could benefit from increasing up-to-date industry-specific training and education on highly infectious disease risk mitigation and management. Professional death care sector organizations are positioned to disseminate information, training, and best practices.

A Brief History of Biocontainment

The concept of clinical biocontainment, otherwise known as high-level containment care (HLCC), had its birth among a confluence of near-simultaneous events in 1969. The U.S. Army's Medical Research Institute of Infectious Diseases (USAMRIID) began construction of the first modern biocontainment unit that year, and opened the two-bed facility, often referred to as "the Slammer" in 1971. Over its 41-year existence, 21 persons exposed to highly hazardous infectious diseases were admitted to the Slammer, but none ever contracted the disease to which they had been exposed. Owing, in part, to this underutilization, some questioned the utility of HLCC units. This concern notwithstanding, Emory University and the University of Nebraska opened HLCC units in civilian academic medical centers in 2004 and 2005, respectively. These units, distinct from conventional infectious disease isolation wards found in most major medical centers, proved their worth during the West African Ebola Virus Disease (EVD) outbreak of 2014-2015. It is our opinion that such units, as well as the parallel high-level containment transport systems necessary to move patients to them, will continue to play an important role in the global response to emerging and highly hazardous contagious pathogens. Moreover, we feel that the lessons derived from their successful operation will lead to improvements in infection control procedures and practices throughout the healthcare system.

Current Capabilities and Capacity of Ebola Treatment Centers in the United States

OBJECTIVE

To describe current Ebola treatment center (ETC) locations, their capacity to care for Ebola virus disease patients, and infection control infrastructure features.

DESIGN

A 19-question survey was distributed electronically in April 2015. Responses were collected via email by June 2015 and analyzed in an electronic spreadsheet.

SETTING

The survey was sent to and completed by site representatives of each ETC.

PARTICIPANTS

The survey was sent to all 55 ETCs; 47 (85%) responded.

RESULTS

Of the 47 responding ETCs, there are 84 isolation beds available for adults and 91 for children; of these pediatric beds, 35 (38%) are in children's hospitals. In total, the simultaneous capacity of the 47 reporting ETCs is 121 beds. On the basis of the current US census, there are 0.38 beds per million population. Most ETCs have negative pressure isolation rooms, anterooms, and a process for category A waste sterilization, although only 11 facilities (23%) have the capability to sterilize infectious waste on site.

CONCLUSIONS

Facilities developed ETCs on the basis of Centers for Disease Control and Prevention guidance, but specific capabilities are not mandated at this present time. Owing to the complex and costly nature of Ebola virus disease treatment and variability in capabilities from facility to facility, in conjunction with the lack of regulations, nationwide capacity in specialized facilities is limited. Further assessments should determine whether ETCs can adapt to safely manage other highly infectious disease threats.

[Structural requirements for the management of patients with highly contagious life-threatening infectious diseases: update 2015]

The care of highly contagious life-threatening infectious diseases (HLID) requires specialized treatment facilities that are capable of strict isolation measures and appropriate medical treatment. The German approach to the management of these diseases, which is maintained by the Permanent Working Group of Medical Competence and Treatment Centers for Highly Contagious and Life-Threatening Diseases (STAKOB) is adjusted in the present publication with regards to recent experiences and upcoming needs. Clear synergies in using infrastructures and bundling of resources have led to similar efforts at the European level. The German concept, therefore, has a pioneering role. This update is intended to improve professional patient care and also minimize the risk of disease spread and transmission.

Transportation capacity for patients with highly infectious diseases in Europe: a survey in 16 nations

Highly infectious diseases (HIDs) are defined as being transmissible from person to person, causing life-threatening illnesses and presenting a serious public health hazard. In most European Union member states specialized isolation facilities are responsible for the management of such cases. Ground ambulances are often affiliated with those facilities because rapid relocation of patients is most desirable. To date, no pooled data on the accessibility, technical specifications and operational procedures for such transport capacities are available. During 2009, the ‘European Network for HIDs’ conducted a cross-sectional analysis of hospitals responsible for HID patients in Europe including an assessment of (a) legal aspects; (b) technical and infrastructure aspects; and (c) operational procedures for ground ambulances used for HID transport. Overall, 48 isolation facilities in 16 European countries were evaluated and feedback rates ranged from 78% to 100% (n = 37 to n = 48 centres). Only 46.8% (22/47) of all centres have both national and local guidelines regulating HID patient transport. If recommended, specific equipment is found in 90% of centres (9/10), but standard ambulances in only 6/13 centres (46%). Exclusive entrances (32/45; 71%) and pathways (30/44; 68.2%) for patient admission, as well as protocols for disinfection of ambulances (34/47; 72.3%) and equipment (30/43; 69.8%) exist in most centres. In conclusion, the availability and technical specifications of ambulances broadly differ, reflecting different preparedness levels within the European Union. Hence, regulations for technical specifications and operational procedures should be harmonized to promote patient and healthcare worker safety.

Personal Protective Equipment Management and Policies: European Network for Highly Infectious Diseases Data from 48 Isolation Facilities in 16 European Countries

Objective.

To collect data about personal protective equipment (PPE) management and to provide indications for improving PPE policies in Europe.

Design.

Descriptive, cross-sectional survey.

Setting and Participants.

Data were collected in 48 isolation facilities in 16 European countries nominated by National Health Authorities for the management of highly infectious diseases (HIDs).

Methods.

Data were collected through standardized checklists at on-site visits during February-November 2009. Indications for adequate PPE policies were developed on the basis of a literature review, partners' expert opinions, and the collected data.

Results.

All facilities have procedures for the selection of PPE in case of HID, and 44 have procedures for the removal of PPE. In 40 facilities, different levels of PPE are used according to a risk assessment process, and in 8 facilities, high-level PPE (eg, positive-pressure complete suits or Trexler units) is always used. A fit test is performed at 25 of the 40 facilities at which it is applicable, a seal check is recommended at 25, and both procedures are used at 17. Strategies for promoting and monitoring the correct use of PPE are available at 42 facilities. In case of a sudden increase in demand, 44 facilities have procedures for rapid supply of PPE, whereas 14 facilities have procedures for decontamination and reuse of some PPE.

Conclusions.

Most isolation facilities devote an acceptable level of attention to PPE selection and removal, strategies for the promotion of the correct use of PPE, and ensuring adequate supplies of PPE. Fit test and seal check procedures are still not widely practiced. Moreover, policies vary widely between and within European countries, and the development of common practice procedures is advisable.

Infect Control Hosp Epidemiol 2012;33(10):1008-1016

Isolation facilities for highly infectious diseases in Europe--a cross-sectional analysis in 16 countries

BACKGROUND

Highly Infectious Diseases (HIDs) are (i) easily transmissible form person to person; (ii) cause a life-threatening illness with no or few treatment options; and (iii) pose a threat for both personnel and the public. Hence, even suspected HID cases should be managed in specialised facilities minimizing infection risks but allowing state-of-the-art critical care. Consensus statements on the operational management of isolation facilities have been published recently. The study presented was set up to compare the operational management, resources, and technical equipment among European isolation facilities. Due to differences in geography, population density, and national response plans it was hypothesized that adherence to recommendations will vary.

METHODS AND FINDINGS

Until mid of 2010 the European Network for Highly Infectious Diseases conducted a cross-sectional analysis of isolation facilities in Europe, recruiting 48 isolation facilities in 16 countries. Three checklists were disseminated, assessing 44 items and 148 specific questions. The median feedback rate for specific questions was 97.9% (n = 47/48) (range: n = 7/48 (14.6%) to n = 48/48 (100%). Although all facilities enrolled were nominated specialised facilities' serving countries or regions, their design, equipment and personnel management varied. Eighteen facilities fulfilled the definition of a High Level Isolation Unit'. In contrast, 24 facilities could not operate independently from their co-located hospital, and five could not ensure access to equipment essential for infection control. Data presented are not representative for the EU in general, as only 16/27 (59.3%) of all Member States agreed to participate. Another limitation of this study is the time elapsed between data collection and publication; e.g. in Germany one additional facility opened in the meantime.

CONCLUSION

There are disparities both within and between European countries regarding the design and equipment of isolation facilities. With regard to the International Health Regulations, terminology, capacities and equipment should be standardised.

Different types of door-opening motions as contributing factors to containment failures in hospital isolation rooms

Hospital isolation rooms are vital for the containment (when under negative pressure) of patients with, or the protection (when under positive pressure) of patients, from airborne infectious agents. Such facilities were essential for the management of highly contagious patients during the 2003 severe acute respiratory syndrome (SARS) outbreaks and the more recent 2009 A/H1N1 influenza pandemic. Many different types of door designs are used in the construction of such isolation rooms, which may be related to the space available and affordability. Using colored food dye as a tracer, the qualitative effects of door-opening motions on the dissemination of potentially contaminated air into and out of a single isolation room were visualized and filmed using Reynolds-number-equivalent, small-scale, water-tank models fitted with programmable door-opening and moving human figure motions. Careful scaling considerations involved in the design and construction of these water-tank models enabled these results to be accurately extrapolated to the full-scale situation. Four simple types of door design were tested: variable speed single and double, sliding and hinged doors, in combination with the moving human figure. The resulting video footage was edited, synchronized and presented in a series of split-screen formats. From these experiments, it is clear that double-hinged doors pose the greatest risk of leakage into or out of the room, followed by (in order of decreasing risk) single-hinged, double-sliding and single-sliding doors. The relative effect of the moving human figure on spreading any potential contamination was greatest with the sliding doors, as the bulk airflows induced were large relative to those resulting from these door-opening motions. However, with the hinged doors, the airflows induced by these door-opening motions were significantly greater. Further experiments involving a simulated ventilated environment are required, but from these findings alone, it appears that sliding-doors are far more effective for hospital isolation room containment.

Decontamination of a hospital room using gaseous chlorine dioxide: Bacillus anthracis, Francisella tularensis, and Yersinia pestis

This study assessed the efficacy of gaseous chlorine dioxide for inactivation of Bacillus anthracis, Francisella tularensis, and Yersinia pestis in a hospital patient care suite. Spore and vegetative cells of Bacillus anthracis Sterne 34F2, spores of Bacillus atrophaeus ATCC 9372 and vegetative cells of both Francisella tularensis ATCC 6223 and Yersinia pestis A1122 were exposed to gaseous chlorine dioxide in a patient care suite. Organism inactivation was then assessed by log reduction in viable organisms postexposure to chlorine dioxide gas compared to non-exposed control organism. Hospital room decontamination protocols utilizing chlorine dioxide gas concentrations of 377 to 385 ppm maintained to exposures of 767 ppm-hours with 65% relative humidity consistently achieved complete inactivation of B. anthracis and B. atrophaeus spores, as well as vegetative cells of B. anthracis, F. tularensis, and Y. pestis. Decrease in exposure (ppm-hours) and relative humidity (<65%) or restricting airflow reduced inactivation but achieved >8 log reductions in organisms. Up to 10-log reductions were achieved in a hospital room with limited impact on adjacent areas, indicating chlorine dioxide concentrations needed for decontamination of highly concentrated (>6 logs) organisms can be achieved throughout a hospital room. This study translates laboratory chlorine dioxide fumigation studies applied in a complex clinical environment.

Fast-track ventilation strategy to cater for pandemic patient isolation surges

BACKGROUND

The shortage of isolation facilities in hospitals was highlighted during the severe acute respiratory syndrome (SARS) pandemic in 2003. Yet, as the nature and scale of future pandemics cannot be adequately estimated, it is difficult to justify construction of sufficient isolation facilities. A fast-track and cost-effective ventilation strategy for the retrofitting of existing general wards could help hospitals deal with patient surges.

AIM

This article reviews the effectiveness of a fast-track, makeshift isolation approach employed during the SARS outbreak which involved installing simple window-mounted exhaust fans to create negative-pressure airflow in hospital general wards.

METHODS

Computational fluid dynamics (CFD) was used to assess by simulation whether the approach adopted meets US Centers for Disease and Control and Prevention requirements for properly constructed isolation wards.

FINDINGS

CFD simulation revealed that this makeshift approach could match the ventilation standards of isolation rooms. The approach was certainly effective as no secondary infections were reported in hospitals that used it during SARS.

CONCLUSIONS

When there is a shortfall in isolation facilities to accommodate a surge in patients, the proposed ventilation set-up could be quickly and widely implemented by existing general wards.