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

On-The-Spot Sampling and Detection of Viral Particles on Solid Surfaces Using a Sponge Virus Sensor Incorporated with Finger-Press Fluid Release

This paper presents a sponge-based electrochemical sensor for rapid, on-site collection and analysis of infectious viruses on solid surfaces. The device utilizes a conducting porous sponge modified with graphene, graphene oxide, and specific antibodies. The sponge serves as a hydrophilic porous electrode capable of liquid collection and electrochemical measurements. The device operation involves spraying an aqueous solution on a target surface, swiping the misted surface using the sponge, discharging an electrolyte solution with a simple finger press, and performing in situ incubation and electrochemical measurements. By leveraging the water-absorbing ability of the biofunctionalized conducting sponge, the sensor can effectively collect and quantify virus particles from the surface. The portability of the device is enhanced by introducing a push-release feature that dispenses the liquid electrolyte from a miniature reservoir onto the sensor surface. This reservoir has sharp edges to rupture a liquid sealing film with a finger press. The ability of the device to sample and quantify viral particles is demonstrated by using influenza A virus as the model. The sensor provided a calculated limit of detection of 0.4 TCID50/mL for H1N1 virus, along with a practical concentration range from 1-106 TCID50/mL. Additionally, it achieves a 15% collection efficiency from single-run swiping on a tabletop surface. This versatile device allows for convenient on-site virus detection within minutes, eliminating the need for sample pretreatment and simplifying the entire sample collecting and measuring process. This device presents significant potential for rapid virus detection on solid surfaces.

Exhaled patient derived aerosol dispersion during awake tracheal intubation with concurrent high flow nasal therapy

Awake Tracheal Intubation (ATI) can be performed in cases where there is potential for difficult airway management. It is considered an aerosol generating procedure and is a source of concern to healthcare workers due to the risk of transmission of airborne viral infections, such as SARS-CoV-2. At present, there is a lack of data on the quantities, size distributions and spread of aerosol particles generated during such procedures. This was a volunteer observational study which took place in an operating room of a university teaching hospital. Optical particle sizers were used to provide real time aerosol characterisation during a simulated ATI performed with concurrent high-flow nasal oxygen therapy. The particle sizers were positioned at locations that represented the different locations of clinical staff in an operating room during an ATI. The greatest concentration of patient derived aerosol particles was within 0.5-1.0 m of the subject and along their midline, 2242 #/cm3. As the distance, both radial and longitudinal, from the subject increased, the concentration decreased towards ambient levels, 36.9 ± 5.1 #/cm3. Patient derived aerosol particles < 5 µm in diameter remained entrained in the exhaled aerosol plume and fell to the floor or onto the subject. Patient derived particles > 5 µm in diameter broke away from the exhaled plume and spread radially throughout the operating room. Irrespective of distance and ventilation status, full airborne protective equipment should be worn by all staff when ATI is being performed on patients with suspected viral respiratory infections.

A CFD-based framework to assess airborne infection risk in buildings

The COVID-19 pandemic has prompted huge efforts to further the scientific knowledge of indoor ventilation and its relationship to airborne infection risk. Exhaled infectious aerosols are spread and inhaled as a result of room airflow characteristics. Many calculation methods and assertions on risk assume 'well-mixed' flow conditions. However, ventilation in buildings is complex and often not showing well-mixed conditions. Ventilation guidance is typically based on the provision of generic minimum ventilation flow rates for a given space, irrespective of the effectiveness in the delivery of the supply air. Furthermore, the airflow might be heavily affected by the season, the HVAC ventilation, or the opening of windows, which would potentially generate draughts and non-uniform conditions. As a result, fresh air concentration would be variable depending upon a susceptible receptor's position in a room and, therefore, associated airborne infection risk. A computational fluid dynamics (CFD) and dynamic thermal modelling (DTM) framework is proposed to assess the influence of internal airflow characteristics on airborne infection risk. A simple metric is proposed, the hourly airborne infection rate (HAI) which can easily help designers to stress-test the ventilation within a building under several conditions. A case study is presented, and the results clearly demonstrate the importance of understanding detailed indoor airflow characteristics and associated concentration patterns in order to provide detailed design guidance, e.g. occupancy, supply air diffusers and furniture layouts, to reduce airborne infection risk.

Assessment of aerosol persistence in ICUs via low-cost sensor network and zonal models

The COVID-19 pandemic raised public awareness about airborne particulate matter (PM) due to the spread of infectious diseases via the respiratory route. The persistence of potentially infectious aerosols in public spaces and the spread of nosocomial infections in medical settings deserve careful investigation; however, a systematic approach characterizing the fate of aerosols in clinical environments has not been reported. This paper presents a methodology for mapping aerosol propagation using a low-cost PM sensor network in ICU and adjacent environments and the subsequent development of the data-driven zonal model. Mimicking aerosol generation by a patient, we generated trace NaCl aerosols and monitored their propagation in the environment. In positive (closed door) and neutral-pressure (open door) ICUs, up to 6% or 19%, respectively, of all PM escaped through the door gaps; however, the outside sensors did not register an aerosol spike in negative-pressure ICUs. The K-means clustering analysis of temporospatial aerosol concentration data suggests that ICU can be represented by three distinct zones: (1) near the aerosol source, (2) room periphery, and (3) outside the room. The data suggests two-phase plume behavior: dispersion of the original aerosol spike throughout the room, followed by an evacuation phase where "well-mixed" aerosol concentration decayed uniformly. Decay rates were calculated for positive, neutral, and negative pressure operations, with negative-pressure rooms clearing out nearly twice as fast. These decay trends closely followed the air exchange rates. This research demonstrates the methodology for aerosol monitoring in medical settings. This study is limited by a relatively small data set and is specific to single-occupancy ICU rooms. Future work needs to evaluate medical settings with high risks of infectious disease transmission.

A Spatial Kinetic Model of Crowd Evacuation Dynamics with Infectious Disease Contagion

This paper proposes a kinetic theory approach coupling together the modeling of crowd evacuation from a bounded domain with exit doors and infectious disease contagion. The spatial movement of individuals in the crowd is modeled by a proper description of the interactions with people in the crowd and the environment, including walls and exits. At the same time, interactions among healthy and infectious individuals may generate disease spreading if exposure time is long enough. Immunization of the population and individual awareness to contagion is considered as well. Interactions are modeled by tools of game theory, that let us propose the so-called tables of games that are introduced in the general kinetic equations. The proposed model is qualitatively studied and, through a series of case studies, we explore different scenarios related to crowding and gathering formation within indoor venues under the spread of a respiratory infectious disease, obtaining insights on specific policies to reduce contagion that may be implemented.

Analysis on the thermal performance of low-temperature radiant floor coupled with intermittent stratum ventilation (LTR-ISV) for space heating

With increasing energy use and outbreaks of respiratory infectious diseases (such as COVID-19) in buildings, there is a growing interest in creating healthy and energy-efficient indoor environments. A novel heating system named low-temperature radiant floor coupled with intermittent stratum ventilation (LTR-ISV) is proposed in this study. Thermal performance, indoor air quality, energy and exergy performance were investigated and compared with conventional radiant floor heating (CRFH) and conventional radiant floor heating with mixing ventilation (CRFH + MV). The results indicated that LTR-ISV had a more uniform operative temperature distribution and overall thermal sensation, and air mixing was enhanced without generating additional draft sensation. Compared with CRFH and CRFH + MV, the indoor CO₂ concentration in LTR-ISV can be reduced by 1355 ppm and 400 ppm, respectively. Airborne transmission risk can also be reduced by 5.35 times. The coefficient of performance for CRFH, CRFH + MV, and LTR-ISV during working hours was 4.2, 2.5, and 3.4, respectively. The lower value of LTR-ISV was due to the high energy usage of the primary air handing unit. In the non-working hours, LTR-ISV was 0.6 and 1.3 higher compared to CRFH and CRFH + MV, respectively. The exergy efficiency of LTR-ISV, CRFH, and CRFH + MV was 81.77 %, 76.43 %, and 64.71 %, respectively. Therefore, the LTR-ISV system can meet the requirements of high indoor air quality and thermal comfort and provides a reference for the energy-saving use of low-grade energy in space heating.

Increased CO2 levels in the operating room correlate with the number of healthcare workers present: an imperative for intentional crowd control

The air in an operating room becomes more contaminated as the occupancy of the room increases. Individuals residing in a room can potentially emit infectious agents. In order to inhibit and better understand the epidemiology of surgical site infections, it is important to develop procedures to track room occupancy level and respiration. Exhaled CO₂ provides a respiratory byproduct that can be tracked with IR light and is associated with human occupancy. Exhaled CO₂ can also be used as an indirect measure of the potential release and level of infectious airborne agents. We show that non-dispersive infrared CO₂ sensors can be used to detect CO₂ in operating room air flow conditions of 20 air changes per hour and a positive pressure of 0.03 in. H₂O. The CO₂ concentration increased consecutively for occupation levels of one to four individuals, from approximately 65 ppm above the background level when one individual occupied the operating room for twenty minutes to approximately 300 ppm above the background when four individuals were present for twenty minutes. The amount of CO₂ detected increases as the number of occupants increase, the activity level increases, the residency time increases and when the ventilation level is reduced.

Bridge the gap: correlate face mask leakage and facial features with 3D morphable face models

BACKGROUND

Face masks have been proven to be effective in protecting the public against airborne transmitted diseases when fitted appropriately. However, for homemade cloth masks and surgical masks, the fit is often poor, allowing viruses to escape through the gap.

OBJECTIVE

This work aims to identify the correlation between the mask leakage, mask configurations, and individual's facial features.

METHODS

A novel locally morphing 3D face model, and a minimum-energy-based mask deployment model are used to systematically examine the mask fit for a large cohort of exemplars.

RESULTS

The results show that the mask size and tuck-in ratio, along with selective facial features, especially nose height and chin length, are key factors determining the leakage location and extent. A polynomial regression model is presented for mask fitness based on localized facial features.

SIGNIFICANCE

This study is a complete pipeline to test various masks on a wide range of faces with controlled modification of distinct regions of the face, which is difficult to achieve with human subjects, and provide knowledge on how the masks should be designed in the future.

IMPACT STATEMENT

The face mask "fit" affects the mask's efficacy in preventing airborne transmission. To date, research on the face mask fit has been conducted mainly using experiments on limited subjects. The limited sample size in experimental studies makes it hard to reach a statistical correlation between mask fit and facial features in a population. Here, we employ a novel framework that utilizes a morphable face model and mask's deployment simulation to test mask fit for many facial characteristics and mask designs. The proposed technique is an important step toward enabling personalized mask selection with maximum efficacy for society members.

Reducing the risk of viral contamination during the coronavirus pandemic by using a protective curtain in the operating room

Background

Airborne transmission diseases can transfer long and short distances via sneezing, coughing, and breathing. These airborne repertory particles can convert to aerosol particles and travel with airflow. During the Coronavirus disease 2019 (COVID-19) pandemic, many surgeries have been delayed, increasing the demand for establishing a clean environment for both patient and surgical team in the operating room.

Methods

This study aims to investigate the hypothesis of implementing a protective curtain to reduce the transmission of infectious contamination in the surgical microenvironment of an operating room. In this regard, the spread of an airborne transmission disease from the patient was evaluated, consequently, the exposure level of the surgical team. In the first part of this study, a mock surgical experiment was established in the operating room of an academic medical center in Norway. In the second part, the computational fluid dynamic technique was performed to investigate the spread of airborne infectious diseases. Furthermore, the field measurement was used to validate the numerical model and guarantee the accuracy of the applied numerical models.

Results

The results showed that the airborne infectious agents reached the breathing zone of the surgeons. However, using a protective curtain to separate the microenvironment between the head and lower body of the patient resulted in a 75% reduction in the spread of the virus to the breathing zone of the surgeons. The experimental results showed a surface temperature of 40 ˚C, which was about a 20 ˚C increase in temperature, at the wound area using a high intensity of the LED surgical lamps. Consequently, this temperature increase can raise the patient's thermal injury risk.

Conclusion

The novel method of using a protective curtain can increase the safety of the surgical team during the surgery with a COVID-19 patient in the operating room.

Uncertainty analysis of facemasks in mitigating SARS-CoV-2 transmission

In the context of global spread of coronavirus disease 2019 (COVID-19) caused by a novel coronavirus (SARS-CoV-2), there is a controversial issue on whether the use of facemasks is promising to control or mitigate the COVID-19 transmission. This study modeled the SARS-CoV-2 transmission process and analyzed the ability of surgical mask and N95 in reducing the infection risk with Sobol's analysis. Two documented outbreaks of COVID-19 with no involvers wearing face masks were reviewed in a restaurant in Guangzhou (China) and a choir rehearsal in Mount Vernon (USA), suggesting that the proposed model can be well validated when airborne transmission is assumed to dominate the virus transmission indoors. Subsequently, the uncertainty analysis of the protection efficiency of N95 and surgical mask were conducted with Monte Carlo simulations, with three main findings: (1) the uncertainty in infection risk is primarily apportioned by respiratory activities, virus dynamics, environment factors and individual exposures; (2) wearing masks can effectively reduce the SARS-CoV-2 infection risk to an acceptable level (< 10^-3) by at least two orders of magnitude; (3) faceseal leakage can reduce protection efficiency by approximately 4% when the infector is speaking or coughing, and by approximately 28% when the infector is sneezing. This work indicates the effectiveness of non-pharmaceutical interventions during the pandemic, and implies the importance of the synergistic studies of medicine, environment, social policies and strategies, etc., on reducing hazards and risks of the pandemic.

Experimental study on the exposure level of surgical staff to SARS-CoV-2 in operating rooms with mixing ventilation under negative pressure

The purpose of this study was to reveal the exposure level of surgical staff to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from the patient's nose and wound during operations on COVID-19 patients. The tracer gas N₂O is used to simulate SARS-CoV-2 from the patient's nose and wound. In this study, concentration levels of tracer gas were measured in the breathing zones of these surgical staff in the operating room under three pressure difference conditions: -5 pa-15 pa and -25 pa compared to the adjunction room. These influencing factors on exposure level are analyzed in terms of ventilation efficiency and the thermal plume distribution characteristics of the patient. The results show that the assistant surgeon faces 4 to 12 times higher levels of exposure to SARS-CoV-2 than other surgical staff. Increasing the pressure difference between the OR lab and adjunction room can reduce the level of exposure for the main surgeon and assistant surgeon. Turning on the cooling fan of the endoscope imager may result in a higher exposure level for the assistant surgeon. Surgical nurses outside of the surgical microenvironment are exposed to similar contaminant concentration levels in the breathing zone as in the exhaust. However, the ventilation efficiency is not constant near the surgical patient or in the rest of the room and will vary with a change in pressure difference. This may suggest that the air may not be fully mixed in the surgical microenvironment.

Airborne and aerosol pathogen transmission modeling of respiratory events in buildings: An overview of computational fluid dynamics

Pathogen droplets released from respiratory events are the primary means of dispersion and transmission of the recent pandemic of COVID-19. Computational fluid dynamics (CFD) has been widely employed as a fast, reliable, and inexpensive technique to support decision-making and to envisage mitigatory protocols. Nonetheless, the airborne pathogen droplet CFD modeling encounters limitations due to the oversimplification of involved physics and the intensive computational demand. Moreover, uncertainties in the collected clinical data required to simulate airborne and aerosol transport such as droplets' initial velocities, tempo-spatial profiles, release angle, and size distributions are broadly reported in the literature. There is a noticeable inconsistency around these collected data amongst many reported studies. This study aims to review the capabilities and limitations associated with CFD modeling. Setting the CFD models needs experimental data of respiratory flows such as velocity, particle size, and number distribution. Therefore, this paper briefly reviews the experimental techniques used to measure the characteristics of airborne pathogen droplet transmissions together with their limitations and reported uncertainties. The relevant clinical data related to pathogen transmission needed for postprocessing of CFD data and translating them to safety measures are also reviewed. Eventually, the uncertainty and inconsistency of the existing clinical data available for airborne pathogen CFD analysis are scurtinized to pave a pathway toward future studies ensuing these identified gaps and limitations.

Exposure Risk to Medical Staff in a Nasopharyngeal Swab Sampling Cabin under Four Different Ventilation Strategies

Medical staff working in a nasopharyngeal swab sampling cabin are exposed to a higher exposure risk of COVID-19. In this study, computational fluid dynamics (CFD) are used to evaluate the exposure risk to medical staff in a nasopharyngeal swab sampling cabin of Chinese customs under four different ventilation strategies, i.e., multiple supply fans ventilation (MSFV), multiple exhaust fans ventilation (MEFV), single exhaust fan and outer windows closed ventilation (SEFV), and single exhaust fan and outer windows opened ventilation (SEFV-W). The impact of physical partitions on exposure risk is also discussed. The results show that MSFV performed best in reducing exposure risk. No significant difference was found between MEFV and SEFV. SEFV-W performed better than SEFV with a ventilation rate of 10–50 L/(s∙Person), while it performed worse with a ventilation rate of 50–90 L/(s∙Person). The exposure risk to medical staff did not decrease linearly with the increase in the ventilation flow rate under the four ventilation strategies. For MSFV, the installation of partitions is conducive to the reduction in the exposure risk. This study is expected to provide some guidance for ventilation designs in sampling cabins.

Influence of wearing masks on exhaled air aerodynamics

Since aerosol inhalation is the most common mechanism for COVID-19 infection, the respiratory protective devices (RPDs) have the highest importance in personal protection. The aim of this study was to assess the efficiency of 10 different RPDs in shortening the travelling distance of exhaled air by range measurement using the schlieren imaging technique. When a RPD is worn by a person resting in a seated position, the expired air does not exceed the human convective boundary layer (CBL). Instead, the CBL lifts the expired aerosols vertically up. Thus, they have a prolonged travelling time in the surrounding air and become less harmful by several mechanisms of virus content decay. Coughing as well as expiration valves can cause far reaching expiration air clouds that cross horizontally the human CBL by opening leakage airway corridors into different directions. Measured by the range of expired air an FFP2 mask provided high security under all conditions tested. A non-vented full-face mask with two viral filters performed even better because of its airtight fit and the excellent filtering capacity of the viral filters during inspiration and expiration, even during cough manoeuvres.

High attack rate in a Tong Lau house outbreak of COVID-19 with subdivided units in Hong Kong

Poor housing conditions are known to be associated with infectious diseases such as high Coronavirus disease 2019 (COVID-19) incidences. Transmission causes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in poor housing conditions can be complex. An understanding of the exact mechanism of transmission can help to pinpoint contributing environmental issues. Here, we investigated a Hong Kong COVID-19 outbreak in early 2021 in four traditional Tong Lau houses with subdivided units. There are more than 80 subdivided units of less than 20 m² floor area each on average. With a total of 34 confirmed COVID-19 cases, the outbreak had an attack rate of 25.4%, being one of the highest attack rates observed in Hong Kong, and ranked among the highest attack rates in reported outbreaks internationally. Tracer gas leakage and decay measurements were performed in the drainage system and in the subdivided units to determine the transport of infectious aerosols by the owner-modified sophisticated wastewater drainage pipe networks and the poor ventilation conditions in some subdivided units. The results show that the outbreak was probably due to multiple transmission routes, i.e. by the drainage pipe spread of stack aerosols, which is enhanced by poor ventilation in the subdivided units.

The spread of breathing air from wind instruments and singers using schlieren techniques

The spread of breathing air when playing wind instruments and singing was investigated and visualized using two methods: (1) schlieren imaging with a schlieren mirror and (2) background-oriented schlieren (BOS). These methods visualize airflow by visualizing density gradients in transparent media. The playing of professional woodwind and brass instrument players, as well as professional classical trained singers were investigated to estimate the spread distances of the breathing air. For a better comparison and consistent measurement series, a single high note, a single low note, and an extract of a musical piece were investigated. Additionally, anemometry was used to determine the velocity of the spreading breathing air and the extent to which it was quantifiable. The results showed that the ejected airflow from the examined instruments and singers did not exceed a spreading range of 1.2 m into the room. However, differences in the various instruments have to be considered to assess properly the spread of the breathing air. The findings discussed below help to estimate the risk of cross-infection for wind instrument players and singers and to develop efficacious safety precautions, which is essential during critical health periods such as the current COVID-19 pandemic.

Control of exhaled SARS-CoV-2-laden aerosols in the interpersonal breathing microenvironment in a ventilated room with limited space air stability

The Coronavirus Disease 2019 (COVID-19) highlights the importance of understanding and controlling the spread of the coronavirus between persons. We experimentally and numerically investigated an advanced engineering and environmental method on controlling the transmission of airborne SARS-CoV-2-laden aerosols in the breathing microenvironment between two persons during interactive breathing process by combining the limited space air stability and a ventilation method. Experiments were carried out in a full-scale ventilated room with different limited space air stability conditions, i.e., stable condition, neutral condition and unstable condition. Two real humans were involved to conducted normal breathing process in the room and the exhaled carbon dioxide was used as the surrogate of infectious airborne SARS-CoV-2-laden aerosols from respiratory activities. A correspondent numerical model was established to visualize the temperature field and contaminated field in the test room. Results show that the performance of a ventilation system on removing infectious airborne SARS-CoV-2-laden aerosols from the interpersonal breathing microenvironment is dependent on the limited space air stability conditions. Appropriate ventilation method should be implemented based on an evaluation of the air condition. It is recommended that total volume ventilation methods are suitable for unstable and neutral conditions and local ventilation methods are preferable for stable conditions. This study provides an insight into the transmission of airborne SARS-CoV-2-laden aerosols between persons in ventilated rooms with different limited space air stability conditions. Useful guidance has been provided to cope with COVID-19 in limited spaces.

The Impact of Community Housing Characteristics and Epidemic Prevention Measures on Residents' Perception of Epidemic Prevention

Since the outbreak of COVID-19, many parts of the world have fallen into deep recession. Governments in every country have adopted various measures to restrict social gatherings due to the need to control the pandemic. This includes restrictions on activities in homes and communities. Fundamentally, epidemic prevention relies on the measures individuals take. A community’s epidemic prevention measures become more critical as activities are held in houses or communities once again. From the perspective of the theory of planned behavior, this study investigates whether the various epidemic prevention measures and characteristics of a community affect residents’ perception of epidemic prevention. We use the truncated regression model as the primary research method. The empirical results show that the community’s epidemic prevention measures can change residents’ awareness of the importance of epidemic prevention. Moreover, the scale of the community and management committee are also found to have a partial impact.

High-Fidelity Simulation of Pathogen Propagation, Transmission and Mitigation in the Built Environment

An overview of high-fidelity modeling of pathogen propagation, transmission and mitigation in the built environment is given. In order to derive the required physical and numerical models, the current understanding of pathogen, and in particular virus transmission and mitigation is summarized. The ordinary and partial differential equations that describe the flow, the particles and possibly the UV radiation loads in rooms or HVAC ducts are presented, as well as proper numerical methods to solve them in an expedient way. Thereafter, the motion of pedestrians, as well as proper ways to couple computational fluid dynamics and computational crowd dynamics to enable high-fidelity pathogen transmission and infection simulations is treated. The present review shows that high-fidelity simulations of pathogen propagation, transmission and mitigation in the built environment have reached a high degree of sophistication, offering a quantum leap in accuracy from simpler probabilistic models. This is particularly the case when considering the propagation of pathogens via aerosols in the presence of moving pedestrians.

Real-time imaging of airflow patterns and impact of infection control measures in ophthalmic practice: a pandemic perspective

PURPOSE

To analyze exhaled airflow patterns in a clinical scenario and the impact of infection control practices and room air circulation in context of the COVID-19 pandemic.

SETTING

Raghudeep Eye Hospital, India.

DESIGN

Experimental study.

METHODS

Ten patients attending ophthalmic outpatient clinic (OPD) and operating room (OR) were included. Using Schlieren imaging, exhaled airflow patterns were documented with/without an N95 mask or face shield during respiratory activities. Recordings were performed with and without room air conditioning turned on. Exhaled airflow patterns in OPD and OR when using vs not using these infection control measures and the impact of room air circulation on these were compared.

RESULTS

Five patients each in OPD and OR were included. There was a forward stream of exhaled air from the patient's mouth/nose during all respiratory activities. An N95 mask dampened its intensity and forward transmission. Taping the mask around the nasal bridge further reduced airflow leakage. A mechanical barrier in front of the patient's face blocked forward propagation of the exhaled airflow. Turning on a forceful and direct draft of air over the surgeon's working area dampened and diverted the exhaled airflow away from the surgeons' breathing area. This effect was particularly pronounced in the OR, with the overhead laminar airflow.

CONCLUSIONS

Using high force airflow with the draft facing downward can dampen and divert the exhaled airflow away from healthcare providers. Using masks/mechanical barriers and taping the mask reduces potential dissemination of aerosols and, thereby, human and surface contamination.

Are Historical Buildings More Adaptive to Minimize the Risks of Airborne Transmission of Viruses and Public Health? A Study of the Hazzazi House in Jeddah (Saudi Arabia)

The coronavirus (COVID-19) pandemic has brought immense challenges to the natural and built environment to develop an antivirus-enabled model for reducing potential risks of spreading the virus at varied scales such as buildings, neighborhoods, and cities. Spatial configurations of structures may hinder or assist the spread of viruses in the built environment. In this study, we have hypothesized that suitable air ventilation in historic buildings may enhance the built environment to combat the spreading of infectious viruses. To provide such quantitative shreds of evidence, we have generated and estimated an integrated model to summarize obtained information by considering natural ventilation, wind speed, inflow and outflow, wind direction, and forecasting the associated risks of airborne disease transmission in a historical building (i.e., the Hazzazi House in particular). Intrinsically, the results have demonstrated that the effectiveness of natural ventilation has directly influenced reducing the risks of transmitting airborne infectious viruses for the selected heritage building in Jeddah (Saudi Arabia). The adopted methods in this research may be useful to understand the potentials of conserving old heritage buildings. Consequently, the results demonstrate that natural air ventilation systems are critical to combat the spread of infectious diseases in the pandemic.

A dynamical overview of droplets in the transmission of respiratory infectious diseases

The outbreak of the coronavirus disease has drawn public attention to the transmission of infectious pathogens, and as major carriers of those pathogens, respiratory droplets play an important role in the process of transmission. This Review describes respiratory droplets from a physical and mechanical perspective, especially their correlation with the transmission of infectious pathogens. It covers the important aspects of (i) the generation and expulsion of droplets during respiratory activities, (ii) the transport and evolution of respiratory droplets in the ambient environment, and (iii) the inhalation and deposition of droplets in the human respiratory tract. State-of-the-art experimental, computational, and theoretical models and results are presented, and the corresponding knowledge gaps are identified. This Review stresses the multidisciplinary nature of its subject and appeals for collaboration among different fields to fight the present pandemic.

A comparison of anesthetic protective barriers for the management of COVID-19 pediatric patients

BACKGROUND

Barrier techniques, such as plastic sheets or intubation boxes, are purported to offer additional protection for healthcare workers.

AIMS

To assess the functionality, perceived safety, droplet protection, and aerosol protection of several barrier techniques.

METHODS

Firstly, a simulation study with 12 different laryngoscopists was conducted to assess the time taken to perform an intubation (via direct laryngoscopy, via video laryngoscopy, and via a bougie) with four different barrier techniques (personal protective equipment only, a plastic sheet, a tented plastic sheet, and an intubation box). Secondly, a cough at the time of intubation was simulated using ultraviolet dye to assess the spread of droplets; and thirdly, smoke was used to assess the spread of aerosols.

RESULTS

Intubation time using the box was noninferior to using no barrier. Based on subjective ratings by the laryngoscopists, the most functional technique was no barrier followed by the intubation box, then the tented sheet, and then the plastic sheet. The technique that conferred the highest feeling of safety to the laryngoscopists was the intubation box, followed by the tented sheet, then no barrier, and then the plastic sheet. All the barriers prevented the ultraviolet dye contaminating the head and torso of the laryngoscopist. Smoke remained within the intubation box if plastics sheets were used to cover the openings and suction was ineffective at clearing it. With no barrier in place, smoke was effectively cleared away from the patient in a theater with laminar flow but tended to spread up toward the laryngoscopist in a room without laminar flow.

CONCLUSIONS

A well-designed intubation box is an effective barrier against droplets and is noninferior to no barrier in relation to intubation time. However, a box interferes with laminar flow in theaters with formal ventilation systems and may result in accumulation of aerosols if it is completely enclosed.

Airflow Characteristics in Aeromedical Aircraft: Considerations During COVID-19

Objective

The aeromedical transport of coronavirus patients presents risks to clinicians and aircrew. Patient positioning and physical barriers may provide additional protection during flight. This paper describes airflow testing undertaken on fixed wing and rotary wing aeromedical aircraft.

Methods

Airflow testing was undertaken on a stationary Hawker Beechcraft B200C and Leonardo Augusta Westland 139. Airflow was simulated using a Trainer 101 (MSS Professional A/S, Odense Sø, Syddanmark, Denmark) Smoke machine. Different cabin configurations were used along with variations in heating, cooling, and ventilation systems.

Results

For the Hawker Beechcraft B200C, smoke generated within the forward section of the cabin was observed to fill the cabin to a fluid boundary located in-line with the forward edge of the cargo door. With the curtain closed, smoke was only observed to enter the cockpit in very small quantities. For the Leonardo AW139, smoke generated within the cabin was observed to expand to fill the cabin evenly before dissipating. With the curtain closed, smoke was observed to enter the cockpit only in small quantities

Conclusion

The use of physical barriers in fixed wing and rotary wing aeromedical aircraft provides some protection to aircrew. Optimal positioning of the patient is on the aft stretcher on the Beechcraft B200C and on a laterally orientated stretcher on the AW139. The results provide a baseline for further investigation into methods to protect aircrew during the coronavirus pandemic.

Face Coverings, Aerosol Dispersion and Mitigation of Virus Transmission Risk

The SARS-CoV-2 virus is primarily transmitted through virus-laden fluid particles ejected from the mouth of infected people. Face covers can mitigate the risk of virus transmission but their outward effectiveness is not fully ascertained. Objective: by using a background oriented schlieren technique, we aim to investigate the air flow ejected by a person while quietly and heavily breathing, while coughing, and with different face covers. Results: we found that all face covers without an outlet valve reduce the front flow through by at least 63% and perhaps as high as 86% if the unfiltered cough jet distance was resolved to the anticipated maximum distance of 2-3 m. However, surgical and handmade masks, and face shields, generate significant leakage jets that may present major hazards. Conclusions: the effectiveness of the masks should mostly be considered based on the generation of secondary jets rather than on the ability to mitigate the front throughflow.

Airflows inside passenger cars and implications for airborne disease transmission

Transmission of highly infectious respiratory diseases, including SARS-CoV-2, is facilitated by the transport of exhaled droplets and aerosols that can remain suspended in air for extended periods of time. A passenger car cabin represents one such situation with an elevated risk of pathogen transmission. Here, we present results from numerical simulations to assess how the in-cabin microclimate of a car can potentially spread pathogenic species between occupants for a variety of open and closed window configurations. We estimate relative concentrations and residence times of a noninteracting, passive scalar-a proxy for infectious particles-being advected and diffused by turbulent airflows inside the cabin. An airflow pattern that travels across the cabin, farthest from the occupants, can potentially reduce the transmission risk. Our findings reveal the complex fluid dynamics during everyday commutes and nonintuitive ways in which open windows can either increase or suppress airborne transmission.

Check the gap: Facemask performance and exhaled aerosol distributions around the wearer

Current facemask research focuses on material characterization and efficiency; however, facemasks are often not tested such that aerosol distributions are evaluated from the gaps in the sides, bottom, and nose areas. Poor evaluation methods could lead to misinformation on optimal facemasks use; a high-throughput, reproducible method which illuminates the issue of fit influencing aerosol transmission is needed. To this end, we have created an in vitro model to quantify particle transmission by mimicking exhalation aerosols in a 3D printed face-nose-mouth replica via a nebulizer and quantifying particle counts using a hand-held particle counter. A sewn, sewn with pipe cleaner nose piece, and sewn with a coffee filter facemask were used to evaluate current common homemade sewn facemask designs, benchmarked against industry standard surgical, N95 respirator tightly fit, and N95 respirator loosely fit facemasks. All facemasks have significantly reduced particle counts in front of the facemask, but the side and top of the facemask showed increases in particle counts over the no facemask condition at that same position, suggesting that some proportion of aerosols are being redirected to these gaps. An altered size distribution of aerosols that escape at the vulnerable positions was observed; escaped particles have larger count median diameters, with a decreased ratio of smaller to larger particles, possibly due to hygroscopic growth or aggregation. Of the homemade sewn facemasks, the facemask with a coffee filter insert performed the best at reducing escaped aerosols, with increased efficiency also observed for sewn masks with a pipe cleaner nose piece. Importantly, there were minimal differences between facemasks at increasing distances, which supports that social distance is a critical element in reducing aerosol transmission. This work brings to light the importance of quantifying particle count in positions other than directly in front of the facemask and identifies areas of research to be explored.

Quantitative assessment of the risk of airborne transmission of SARS-CoV-2 infection: Prospective and retrospective applications

Airborne transmission is a recognized pathway of contagion; however, it is rarely quantitatively evaluated. The numerous outbreaks that have occurred during the SARS-CoV-2 pandemic are putting a demand on researchers to develop approaches capable of both predicting contagion in closed environments (predictive assessment) and analyzing previous infections (retrospective assessment). This study presents a novel approach for quantitative assessment of the individual infection risk of susceptible subjects exposed in indoor microenvironments in the presence of an asymptomatic infected SARS-CoV-2 subject. The application of a Monte Carlo method allowed the risk for an exposed healthy subject to be evaluated or, starting from an acceptable risk, the maximum exposure time. We applied the proposed approach to four distinct scenarios for a prospective assessment, highlighting that, in order to guarantee an acceptable risk of 10^-3 for exposed subjects in naturally ventilated indoor environments, the exposure time could be well below one hour. Such maximum exposure time clearly depends on the viral load emission of the infected subject and on the exposure conditions; thus, longer exposure times were estimated for mechanically ventilated indoor environments and lower viral load emissions. The proposed approach was used for retrospective assessment of documented outbreaks in a restaurant in Guangzhou (China) and at a choir rehearsal in Mount Vernon (USA), showing that, in both cases, the high attack rate values can be justified only assuming the airborne transmission as the main route of contagion. Moreover, we show that such outbreaks are not caused by the rare presence of a superspreader, but can be likely explained by the co-existence of conditions, including emission and exposure parameters, leading to a highly probable event, which can be defined as a "superspreading event".

Full-scale experimental and numerical study of bioaerosol characteristics against cross-infection in a two-bed hospital ward

The transmission and deposition of pathogenic bioaerosols and the subsequent contamination of the air and surfaces is well recognized as a potential route of hospital cross-infection. A full-scale experiment using Bacillus subtilis and computational fluid dynamics were utilized to model the bioaerosol characteristics in a two-bed hospital ward with a constant air change rate (12 ACH). The results indicated that the bioaerosol removal efficiency of unilateral downward ventilation was 50% higher than that of bilateral downward ventilation. Additionally, health care workers (HCWs) and nearby patients had lower breathing zone concentrations in the ward with unilateral downward ventilation. Furthermore, a partition played a positive role in protecting patients by reducing the amount of bioaerosol exposure. However, no obvious protective effect was observed with respect to the HCWs. Only 10% of the bioaerosol was deposited on the surfaces in the ward with unilateral downward ventilation, while up to 35% of the bioaerosol was deposited on the surfaces in the ward with bilateral downward ventilation during the 900 s. The main deposition locations of the bioaerosols were near the wall on the same side of the room as the patient's head in all cases. This study could provide scientific evidence for controlling cross-infection in hospital wards, as well as several guidelines for the disinfection of hospital wards.

Flow visualization of an N95 respirator with and without an exhalation valve using schlieren imaging and light scattering

This work demonstrates the qualitative fluid flow characteristics of a standard N95 respirator with and without an exhalation valve. Schlieren imaging was used to compare an adult male breathing through an N95 respirator with and without a valve. The schlieren imaging technique showed the flow of warm air passing through these respirators but did not provide information about droplet penetration. For this, strategic lighting of fog droplets was used with a mannequin head to visualize the penetration of droplets through both masks. The mannequin exhaled with a realistic flow rate and velocity that matched an adult male. The penetration of fog droplets was also visualized with a custom system that seals each respirator onto the end of a flow tube. Results of these qualitative experiments show that an N95 respirator without an exhalation valve is effective at blocking most droplets from penetrating through the mask material. Results also suggest that N95 respirators with exhalation valves are not appropriate as a source control strategy for reducing the proliferation of infectious diseases that spread via respiratory droplets.

Effect of equipment layout on bioaerosol temporal-spatial distribution and deposition in one BSL-3 laboratory

Reasonable equipment layout is essential for creating a healthy and safe environment, especially in a three-level biosafety laboratory with high potential risk factors of infection. Since 2019, COVID-19, an emerging infection has swept the world and caused severe losses. Biosafety laboratories are mandatory sites for detecting high-risk viruses, so related research is urgently needed to prevent further laboratory-acquired infections of operators. This study investigated the effects of obstacles on exposure infection of staff in a biosafety laboratory with related experimental equipment. The numerical simulation results are highly verified by the measured results. The results indicate that although the equipment layout does not affect the bioaerosol removal time, nearly 17% of the pollutant particles in the actual laboratory cannot be discharged effectively compared with the ideal situation. These particles lingered in the lower space under the influence of vortex, which would increase the respiratory risk of operators. In addition, after the experiment a large part of bioaerosol particles would be captured by equipment and floor, and the deposition rate per unit area is 0.45%/m² and 0.8%/m², respectively. Although the results show that the equipment layout could reduce the pollution on the floor, the disinfection is still an important link, especially on the surfaces of equipment. Meanwhile, the result also indicates that the action should be light and slow when operating in BSL-3 laboratory, so as to avoid the secondary suspension pollution of bioaerosol particles on the equipment surface and floor.

Estimation of airborne viral emission: Quanta emission rate of SARS-CoV-2 for infection risk assessment

Airborne transmission is a pathway of contagion that is still not sufficiently investigated despite the evidence in the scientific literature of the role it can play in the context of an epidemic. While the medical research area dedicates efforts to find cures and remedies to counteract the effects of a virus, the engineering area is involved in providing risk assessments in indoor environments by simulating the airborne transmission of the virus during an epidemic. To this end, virus air emission data are needed. Unfortunately, this information is usually available only after the outbreak, based on specific reverse engineering cases. In this work, a novel approach to estimate the viral load emitted by a contagious subject on the basis of the viral load in the mouth, the type of respiratory activity (e.g. breathing, speaking, whispering), respiratory physiological parameters (e.g. inhalation rate), and activity level (e.g. resting, standing, light exercise) is proposed. The results showed that high quanta emission rates (>100 quanta h^-1) can be reached by an asymptomatic infectious SARS-CoV-2 subject performing vocalization during light activities (i.e. walking slowly) whereas a symptomatic SARS-CoV-2 subject in resting conditions mostly has a low quanta emission rate (<1 quantum h^-1). The findings in terms of quanta emission rates were then adopted in infection risk models to demonstrate its application by evaluating the number of people infected by an asymptomatic SARS-CoV-2 subject in Italian indoor microenvironments before and after the introduction of virus containment measures. The results obtained from the simulations clearly highlight that a key role is played by proper ventilation in containment of the virus in indoor environments.

Estimation of airborne viral emission: Quanta emission rate of SARS-CoV-2 for infection risk assessment

Airborne transmission is a pathway of contagion that is still not sufficiently investigated despite the evidence in the scientific literature of the role it can play in the context of an epidemic. While the medical research area dedicates efforts to find cures and remedies to counteract the effects of a virus, the engineering area is involved in providing risk assessments in indoor environments by simulating the airborne transmission of the virus during an epidemic. To this end, virus air emission data are needed. Unfortunately, this information is usually available only after the outbreak, based on specific reverse engineering cases. In this work, a novel approach to estimate the viral load emitted by a contagious subject on the basis of the viral load in the mouth, the type of respiratory activity (e.g. breathing, speaking, whispering), respiratory physiological parameters (e.g. inhalation rate), and activity level (e.g. resting, standing, light exercise) is proposed. The results showed that high quanta emission rates (>100 quanta h^-1) can be reached by an asymptomatic infectious SARS-CoV-2 subject performing vocalization during light activities (i.e. walking slowly) whereas a symptomatic SARS-CoV-2 subject in resting conditions mostly has a low quanta emission rate (<1 quantum h^-1). The findings in terms of quanta emission rates were then adopted in infection risk models to demonstrate its application by evaluating the number of people infected by an asymptomatic SARS-CoV-2 subject in Italian indoor microenvironments before and after the introduction of virus containment measures. The results obtained from the simulations clearly highlight that a key role is played by proper ventilation in containment of the virus in indoor environments.

Universal trends in human cough airflows at large distances

Coughs are one of the primary means of transmission of diseases such as influenza and SARS-CoV-2 (COVID-19). Disease spreading occurs by the expulsion of pathogen containing aerosol droplets. Fine droplets can pass through layers of masks and are carried away by the exhaled airflow unlike larger droplets that settle down due to gravity. Hence, it is important to quantitatively assess the maximum distance of travel of typical human coughs with and without different types of masks. Even though near field data are available near the mouth, far field data are scarce. In this study, the schlieren method that is a highly sensitive, non-intrusive flow visualization technique is used. It can directly image weak density gradients produced by coughs. An assessment of different methods of covering the mouth while coughing is arrived at by using observations from high speed schlieren images. The effectiveness of coughing into the elbow is examined. The velocity of propagation of coughs and the distance of propagation with and without masks are quantified. It is also found that normalizing the distance-velocity profiles causes all the data to collapse onto a universal non-dimensional curve irrespective of the usage of different types of masks or test subjects. Visualization of cough flow fields and analysis of experimental data reveal that the flow physics is governed by the propagation of viscous vortex rings.

Experimental and numerical study of potential infection risks from exposure to bioaerosols in one BSL-3 laboratory

Laboratory-acquired infections (LAIs) are defined as infections of laboratory staff by exposure to pathogenic microorganisms during an experimental procedure. For a biosafety level-3 (BSL-3) laboratory with a high potential of exposure, reducing risks and threats relevant to LAIs has become a critical concern, especially after the recent outbreak of Novel Coronavirus causing COVID-19 in Wuhan, China. This study aimed to investigate the spatial-temporal characteristics of bioaerosol dispersion and deposition of two kinds of bioaerosols (Serratia marcescens and phage ΦX174). A combination of laboratory experiment and numerical simulation was adopted to explore bioaerosol removal. Three-dimensional concentration iso-surface mapping in conjunction with flow field analysis was employed to elucidate bioaerosol migration and deposition behavior. The total deposition number and unit area deposition ratio were calculated for different surfaces. The results indicate that bioaerosol concentration remains stable for up to 400 s after release, and that almost 70% of all bioaerosol particles become deposited on the surfaces of walls and equipment. Vortex flow regions and high-concentration regions were determined, and the most severely contaminated surfaces and locations were identified. Our results could provide the scientific basis for controlling the time interval between different experiments and also provide guidelines for a laboratory disinfection routine. Furthermore, future work regarding laboratory layout optimization and high efficiency air distribution for bioaerosol removal in a BSL-3 laboratory should be emphasized.

Qualitative and quantitative schlieren optical measurement of the human thermal plume

A new large-field, high-sensitivity, single-mirror coincident schlieren optical instrument has been installed at the Bauhaus-Universität Weimar for the purpose of indoor air research. Its performance is assessed by the non-intrusive measurement of the thermal plume of a heated manikin. The schlieren system produces excellent qualitative images of the manikin's thermal plume and also quantitative data, especially schlieren velocimetry of the plume's velocity field that is derived from the digital cross-correlation analysis of a large time sequence of schlieren images. The quantitative results are compared with thermistor and hot-wire anemometer data obtained at discrete points in the plume. Good agreement is obtained, once the differences between path-averaged schlieren data and planar anemometry data are reconciled.

Performance evaluation of ductless personalized ventilation in comparison with desk fans using numerical simulations

The performance of ductless personalized ventilation (DPV) was compared to the performance of a typical desk fan since they are both stand-alone systems that allow the users to personalize their indoor environment. The two systems were evaluated using a validated computational fluid dynamics (CFD) model of an office room occupied by two users. To investigate the impact of DPV and the fan on the inhaled air quality, two types of contamination sources were modeled in the domain: an active source and a passive source. Additionally, the influence of the compared systems on thermal comfort was assessed using the coupling of CFD with the comfort model developed by the University of California, Berkeley (UCB model). Results indicated that DPV performed generally better than the desk fan. It provided better thermal comfort and showed a superior performance in removing the exhaled contaminants. However, the desk fan performed better in removing the contaminants emitted from a passive source near the floor level. This indicates that the performance of DPV and desk fans depends highly on the location of the contamination source. Moreover, the simulations showed that both systems increased the spread of exhaled contamination when used by the source occupant.

How Can Design Features and Other Factors Affect the Indoor Air Quality in Inpatient Rooms? Check-Lists for the Design Phase, Daily Procedures and Maintenance Activities for Reducing the Air Concentrations of Chemical Pollution

Indoor Air Quality (IAQ) is one of main topics of Public Health on which international institutions and countries are taking action. With regards to healing architectures, several studies have reported data analysis and case studies to improve users' health (patients, and medical and administrative staffs), but there are not enough regarding volatile organic compounds (VOCs). Regarding chemical pollution of indoor air, the Scientific Community has highlighted that there are several factors that affect the IAQ, in particular the design and management, and energetic efficiency, of inpatient wards. Several stakeholders, from the designers to the managers, are responsible for the indoor air in healing environments. Supported by analysis of the State of the Art and the main factors that influence the heterogeneous scenario of inpatient wards, the paper presents three check-lists, designed for supporting the stakeholders during the design phase, or for the daily procedures and maintenance activities, for pre-assessment of factors that affect chemical pollution, and for the definition of strategies to be applied. In fact, in such environments IAQ assumes a particular meaning and importance, both for the vulnerability of the patients and for the long time spent by the sanitary staff. The multidisciplinary approach emphasizes the continuous need for interdisciplinary knowledge and skills aimed at finding solutions able to protect users' health status (including patients, workers and visitors), especially in the field of the indoor air issue.

Visualizing the effectiveness of face masks in obstructing respiratory jets

The use of face masks in public settings has been widely recommended by public health officials during the current COVID-19 pandemic. The masks help mitigate the risk of cross-infection via respiratory droplets; however, there are no specific guidelines on mask materials and designs that are most effective in minimizing droplet dispersal. While there have been prior studies on the performance of medical-grade masks, there are insufficient data on cloth-based coverings, which are being used by a vast majority of the general public. We use qualitative visualizations of emulated coughs and sneezes to examine how material- and design-choices impact the extent to which droplet-laden respiratory jets are blocked. Loosely folded face masks and bandana-style coverings provide minimal stopping-capability for the smallest aerosolized respiratory droplets. Well-fitted homemade masks with multiple layers of quilting fabric, and off-the-shelf cone style masks, proved to be the most effective in reducing droplet dispersal. These masks were able to curtail the speed and range of the respiratory jets significantly, albeit with some leakage through the mask material and from small gaps along the edges. Importantly, uncovered emulated coughs were able to travel notably farther than the currently recommended 6-ft distancing guideline. We outline the procedure for setting up simple visualization experiments using easily available materials, which may help healthcare professionals, medical researchers, and manufacturers in assessing the effectiveness of face masks and other personal protective equipment qualitatively.

Measuring the administered dose of particles on the facial mucosa of a realistic human model

Exposure to particulate contaminants can cause serious adverse health effects. Deposition on the facial mucosa is an important path of exposure, but it is difficult to conduct direct dose measurement on real human subjects. In this study, we propose an in vitro method to assess the administered doses of micron-sized particles on the eyes and lips in which computed tomographic scanning and three-dimensional printing were used to create a model that includes a face, oropharynx, trachea, the first five generations of bronchi, and lung volume. This realistic model of a face and airway was exposed to monodispersed fluorescent particles released from an incoming jet. The administered dose of particles deposited upon the eyes and lips, as quantified by fluorescence intensity, was determined via a standard wiping protocol. The results show that, in this scenario, the administered doses normalized by source were 2.15%, 1.02%, 0.88%, 2.13%, and 1.55% for 0.6-, 1.0-, 2.0-, 3.0-, and 5.0-µm particles, respectively. The administered dose of large particles on the mucosa within a given exposure time has great significance. Moreover, the lips suffer a much greater risk of exposure than the eyes and account for more than 80% of total facial mucosa deposition. Our study provides a fast and economical method to assess the administered dose on the facial mucosa on an individual basis.

Detailed simulation of viral propagation in the built environment

A summary is given of the mechanical characteristics of virus contaminants and the transmission via droplets and aerosols. The ordinary and partial differential equations describing the physics of these processes with high fidelity are presented, as well as appropriate numerical schemes to solve them. Several examples taken from recent evaluations of the built environment are shown, as well as the optimal placement of sensors.

Indoor Air Quality in Inpatient Environments: A Systematic Review on Factors that Influence Chemical Pollution in Inpatient Wards

Introduction

Indoor air quality is one the main issues in which governments are focusing. In healing spaces, several research studies are reporting a growing number of data analysis and research works in order to guarantee and prevent health of users and workers. Currently the main investigations are about biological and physical risks; otherwise chemical ones are less investigated. Several countries are carrying out indoor air quality monitoring in those professional workplaces in which chemicals are used but also in some typically indoor (generic) spaces for the building hygiene assessment. The indoor air is affected by several factors that currently are analyzed punctually, without a whole scenario of all the variable performances. The authors have done a systematic review on the current state of the art and knowledge related to chemical pollution in healing spaces and the emerging strategies, supported by scientific literature, for healthy inpatient rooms and their indoor air.

Methodology

The systematic review has been done through the analysis of papers from SCOPUS, DOAJ, and PubMed databases. The survey sample considered 483 scientific articles, between 1989 and 2017, and starting the systematic reading and analysis of the abstracts, only 187 scientific papers were selected, and only 96 were accessible.

Discussion

Since scientific literature reports very different outputs and results, the resulting work from the survey is divided into specific fields of interest related to construction and finishing materials, installations, components, ventilation systems, processes, etc. Starting from the systematic reading, the paper classifies the factors of indoor air in four macroareas: outdoor air and microclimatic factors (temperature, relative humidity, air velocity, air change, etc.); management activities (management and maintenance activities, ventilation systems, HVAC, cleaning and disinfectant activities, etc.); design factors (room dimensions, furniture, finishing materials, etc.); and human presence and medical activities (users' presence, their health status, and medical activities carried out in inpatient rooms).

Conclusion

The systematic review gives rise to a broad scenario on the existing knowledge regarding the indoor air pollution, design, and management strategies for healthy spaces and several emerging topics. Although the aim of the investigation is strictly related to chemical pollution, several considerations from the biological point of view have been listed. The systematic review, supported by the existing scientific literature, becomes a starting point for considering the importance of the topic and to stimulate the knowledge around this field of interest for improving studies, analysis, and simulations.

A review of the chemical and biological pollutants in indoor air in hospitals and assessing their effects on the health of patients, staff and visitors

Indoor air quality in hospitals has been specifically considered in terms of its impact on health. Air quality is an important risk factor influencing the health of staff and patients who are in contact with indoor air inhaled in hospitals. Over the past two decades, hundreds of studies have been developed to assess pollution in hospital environment. Two hundred and fitfy papers from around the world, from the last two decades, were identified and reviewed. Recent studies have found that the presence of various chemical and biological pollutants affected the health of patients, staff and visitors. Nearly all the reports agree that chemical and biological pollutants in the hospital environment have adverse effects. In most of the reviewed papers, analysis of health hazards was conducted for personnel and patients to toxic metals, chlorine, fine (PM2.5) and coarse (PM2.5−10) particles, and bio-aerosol in the inhaled air of the hospital environment. Some papers showed that some of the metals are carcinogens and others do not have a carcinogenic risk. Bio-aerosols as a biological pollutant are usually defined as airborne bacteria, fungi, viruses, pollen and their by products. These biological pollutants are associated with a wide range of health effects in hospital environments. This review can serve as an introduction and as the statement of the problem for more original research in this regard.

Airborne spread of expiratory droplet nuclei between the occupants of indoor environments: A review

This article reviews past studies of airborne transmission between occupants in indoor environments, focusing on the spread of expiratory droplet nuclei from mouth/nose to mouth/nose for non-specific diseases. Special attention is paid to summarizing what is known about the influential factors, the inappropriate simplifications of the thermofluid boundary conditions of thermal manikins, the challenges facing the available experimental techniques, and the limitations of available evaluation methods. Secondary issues are highlighted, and some new ways to improve our understanding of airborne transmission indoors are provided. The characteristics of airborne spread of expiratory droplet nuclei between occupants, which are influenced correlatively by both environmental and personal factors, were widely revealed under steady-state conditions. Owing to the different boundary conditions used, some inconsistent findings on specific influential factors have been published. The available instrumentation was too slow to provide accurate concentration profiles for time-dependent evaluations of events with obvious time characteristics, while computational fluid dynamics (CFD) studies were mainly performed in the framework of inherently steady Reynolds-averaged Navier-Stokes modeling. Future research needs in 3 areas are identified: the importance of the direction of indoor airflow patterns, the dynamics of airborne transmission, and the application of CFD simulations.

An Effective Surrogate Tracer Technique for S. aureus Bioaerosols in a Mechanically Ventilated Hospital Room Replica Using Dilute Aqueous Lithium Chloride

Finding a non-pathogenic surrogate aerosol that represents the deposition of typical bioaerosols in healthcare settings is beneficial from the perspective of hospital facility testing, general infection control and outbreak analysis. This study considers aerosolization of dilute aqueous lithium chloride (LiCl) and sodium chloride (NaCl) solutions as surrogate tracers capable of representing Staphylococcus aureus bioaerosol deposition on surfaces in mechanically ventilated rooms. Tests were conducted in a biological test chamber set up as a replica hospital single patient room. Petri dishes on surfaces were used to collect the Li, Na and S. aureus aerosols separately after release. Biological samples were analyzed using cultivation techniques on solid media, and flame atomic absorption spectroscopy was used to measure Li and Na atom concentrations. Spatial deposition distribution of Li tracer correlated well with S. aureus aerosols (96% of pairs within a 95% confidence interval). In the patient hospital room replica, results show that the most contaminated areas were on surfaces 2 m away from the source. This indicates that the room’s airflow patterns play a significant role in bioaerosol transport. NaCl proved not to be sensitive to spatial deposition patterns. LiCl as a surrogate tracer for bioaerosol deposition was most reliable as it was robust to outliers, sensitive to spatial heterogeneity and found to require less replicates than the S. aureus counterpart to be in good spatial agreement with biological results.

A comparison between tracer gas and aerosol particles distribution indoors: The impact of ventilation rate, interaction of airflows, and presence of objects

The study investigated the separate and combined effects of ventilation rate, free convection flow produced by a thermal manikin, and the presence of objects on the distribution of tracer gas and particles in indoor air. The concentration of aerosol particles and tracer gas was measured in a test room with mixing ventilation. Three layouts were arranged: an empty room, an office room with an occupant sitting in front of a table, and a single-bed hospital room. The room occupant was simulated by a thermal manikin. Monodisperse particles of three sizes (0.07, 0.7, and 3.5 μm) and nitrous oxide tracer gas were generated simultaneously at the same location in the room. The particles and gas concentrations were measured in the bulk room air, in the breathing zone of the manikin, and in the exhaust air. Within the breathing zone of the sitting occupant, the tracer gas emerged as reliable predictor for the exposure to all different-sized test particles. A change in the ventilation rate did not affect the difference in concentration distribution between tracer gas and larger particle sizes. Increasing the room surface area did not influence the similarity in the dispersion of the aerosol particles and the tracer gas.

Pathogen cross-transmission via building sanitary plumbing systems in a full scale pilot test-rig

The WHO Consensus Document on the epidemiology of the SARS epidemic in 2003, included a report on a concentrated outbreak in one Hong Kong housing block which was considered a 'super-spreading event'. The WHO report conjectured that the sanitary plumbing system was one transmission route for the virus. Empty U-traps allowed the aerosolised virus to enter households from the sewerage system. No biological evidence was presented. This research reports evidence that pathogens can be aerosolised and transported on airstreams within sanitary plumbing systems and enter buildings via empty U-traps. A sanitary plumbing system was built, representing two floors of a building, with simulated toilet flushes on the lower floor and a sterile chamber with extractor fan on the floor above. Cultures of a model organism, Pseudomonas putida at 106-109 cfu ml-1 in 0·85% NaCl were flushed into the system in volumes of 6 to 20 litres to represent single or multiple toilet flushes. Air and surface samples were cultured on agar plates and assessed qualitatively and semi-quantitatively. Flushing from a toilet into a sanitary plumbing system generated enough turbulence to aerosolise pathogens. Typical sanitary plumbing system airflows (between 20-30 ls-1) were sufficient to carry aerosolised pathogens between different floors of a building. Empty U-traps allowed aerosolised pathogens to enter the chamber, encouraging cross-transmission. All parts of the system were found to be contaminated post-flush. Empty U-traps have been observed in many buildings and a risk assessment indicates the potential for high risk cross-transmission under defect conditions in buildings with high pathogen loading such as hospitals. Under defective conditions (which are not uncommon) aerosolised pathogens can be carried on the airflows within sanitary plumbing systems. Our findings show that greater consideration should be given to this mode of pathogen transmission.

Human exhalation characterization with the aid of schlieren imaging technique

The purpose of this paper is to determine the dispersion and distribution characteristics of exhaled airflow for accurate prediction of disease transmission. The development of airflow dynamics of human exhalation was characterized using nonhazardous schlieren photography technique, providing a visualization and quantification of turbulent exhaled airflow from 18 healthy human subjects whilst standing and lying. The flow shape of each breathing pattern was characterized by two angles and averaged values of 18 subjects. Two exhaled air velocities, u m and u p , were measured and compared. The mean peak centerline velocity, u m was found to decay correspondingly with increasing horizontal distance x in a form of power function. The mean propagation velocity, u p was found to correlate with physiological parameters of human subjects. This was always lower than u m at the mouth/nose opening, due to a vortex like airflow in front of a single exhalation cycle. When examining the talking and breathing process between two persons, the potential infectious risk was found to depend on their breathing patterns and spatial distribution of their exhaled air. Our study when combined with information on generation and distributions of pathogens could provide a prediction method and control strategy to minimize infection risk between persons in indoor environments.

TR-PIV measurement of exhaled flow using a breathing thermal manikin

Breathing is a high-risk behavior for spreading infectious diseases in enclosed environments, so it is important to investigate the characteristics of human exhalation flow and dispersal of exhaled air to reduce the risk. This paper used two-dimensional time-resolved particle image velocimetry (2D TR-PIV) to measure the exhaled flow from a breathing thermal manikin. Since the exhaled flow is transient and periodic, the phase-averaged method was used to analyze the flow characteristics. The results showed that the velocity profile of the flow exiting the mouth was bell-shaped for exhalation and flat for inhalation. The exhaled flow showed different characteristics during each stage of the exhalation process. In the initial phase, a mushroom-shaped flow arose, while some jet characteristics appeared in the middle phase. The effect of thermal buoyancy and thermal plume on the exhaled flow was analyzed. Clear turbulence characteristics were found in the exhaled flow, and the turbulence fluctuation was very strong in the transition stage between exhalation and inhalation. The last finding was that the distribution and value of vorticity were different in each phase. The results of quantitative PIV provided detailed information about the boundary condition set and validation data for CFD simulation.