Clearing the air. The theory and application of ultraviolet air disinfection

Safety and Effectiveness Assessment of Ultraviolet-C Disinfection in Aircraft Cabins

INTRODUCTION: Aircraft cabins, susceptible to disease transmission, require effective strategies to minimize the spread of airborne diseases. This paper reviews the James Reason Swiss Cheese Theory in mitigating these risks, as implemented by the International Civil Aviation Organization during the COVID-19 pandemic. It also evaluates the use of airborne ultraviolet-C (UV-C) light as an additional protective measure.METHODS: Our approach involved a thorough literature review by experts and a detailed risk-vs.-benefit analysis. The review covered existing research to understand the scientific foundation, while the analysis used established techniques to assess the impact of influenza and COVID-19 in terms of infections, deaths, and economic costs.RESULTS: Integrating UV-C light in aircraft cabins, when applied with appropriate scientific understanding and engineering safeguards, has the potential to reduce in-flight disease transmission. This additional mitigation strategy can work synergistically with existing measures.DISCUSSION: The research and risk-vs.-benefit analysis present strong evidence for the safety and effectiveness of continuous UV-C disinfection in aircraft cabins. It suggests that UV-C light, maintained below exposure limits, can be a valuable addition to existing measures against disease transmission during flights.Belland K, Garcia D, DeJohn C, Allen GR, Mills WD, Glaudel SP. Safety and effectiveness assessment of ultraviolet-C disinfection in aircraft cabins. Aerosp Med Hum Perform. 2024; 95(3):147-157.

Diagnosis, Treatment, and Prevention of Tuberculosis Among People Experiencing Homelessness in the United States: Current Recommendations

OBJECTIVE

Tuberculosis (TB) is a public health problem, especially among people experiencing homelessness (PEH). The Advisory Council for the Elimination of Tuberculosis issued recommendations in 1992 for TB prevention and control among PEH. Our goal was to provide current guidelines and information in one place to inform medical and public health providers and TB programs on TB incidence, diagnosis, and treatment among PEH.

METHODS

We reviewed and synthesized diagnostic and treatment recommendations for TB disease and latent TB infection (LTBI) as of 2022 and information after 1992 on the magnitude of homelessness in the United States, the incidence of TB among PEH, the role of public health departments in TB case management among PEH, and recently published evidence.

RESULTS

In 2018, there were 1.45 million estimated PEH in the United States. During the past 2 decades, the incidence of TB was >10 times higher and the prevalence of LTBI was 7 to 20 times higher among PEH than among people not experiencing homelessness. TB outbreaks were common in overnight shelters. Permanent housing for PEH and the use of rapid TB diagnostic tests, along with isolation and treatment, reduced TB exposure among PEH. The use of direct observation enhanced treatment adherence among PEH, as did involvement of social workers to help secure shelter, food, safety, and treatment for comorbidities, especially HIV and substance use disorders. Testing and treatment for LTBI prevented progression to TB disease, and shorter LTBI regimens helped improve adherence. Federal agencies and the National Health Care for the Homeless Council have helpful resources.

CONCLUSION

Improvements in TB diagnosis, treatment, and prevention among PEH are possible by following existing recommendations and using client-centered approaches.

Attitudes of Healthcare Workers about Prevention and Control of Nosocomial Multidrug-Resistant Tuberculosis Infection in Two Top-Ranked Tuberculosis Specialized Public Hospitals of Ethiopia

Background

Tuberculosis (TB) exists as a human curse since antiquity. Around 9.5 million cases and 1.5 million deaths were reported due to TB in 2021. Ethiopia is one of the high-burdenmultidrug-resistant (MDR) TB countries. MDR-TB is acquired either by poor adherence to treatment or by primary infection with a drug-resistant strain, which has a high transmission rate from patients to healthcare workers (HCWs). Hospital outbreaks of MDR-TB are common in Africa. Hence, this study aimed to score the attitude of HCWs working in the two nationally top-rankedTB-specialized hospitals in Ethiopia, Saint Peter's and ALERT TB-specialized public hospitals about the infection prevention and control (IPC) of nosocomial MDR-TB.

Methods

A cross-sectional study was conducted from December 1, 2020, to March 31, 2021. A simple random sampling method was applied to select 384 HCWs. The data collection tool was a self-administered interview structured questionnaire. The data were analyzed using SPSS software. Descriptive statistics were applied to score attitude. Bivariate and multivariable logistic regression models were performed to identify the independent determinants of attitude. The odds ratio was used to test the degree of association between variables at a 95% confidence interval (CI). The level of statistical significance was fixed at p value < 0.05.

Results

Among the respondents, 87% of the HCWs held favourable attitudes about the nosocomial MDR-TB-IPC. The favourable attitude score had a significant association with the monthly salary earned between 7001 and 9000 ETB (Ethiopian Birr) (AOR = 3.34, 95% CI: 1.11, 10.05) and the previous training obtained on TB/MDR-TB (AOR = 2.96, 95% CI: 1.32, 6.62).

Conclusions

Almost one in seven HCWs has an unfavourable attitude. Prior training received and earning monthly income above 7000 ETB are independent determinants of a favourable attitude score. Refreshment training and a reasonable increment in monthly income should be strengthened in TB-specialized hospitals in Ethiopia.

Airborne Transmission and Control of Influenza and Other Respiratory Pathogens

Despite uncertainty about the specific transmission risk posed by airborne, spray-borne, and contact modes for influenza, SARS-CoV-2, and other respiratory viruses, there is evidence that airborne transmission via inhalation is important and often predominates. An early study of influenza transmission via airborne challenge quantified infectious doses as low as one influenza virion leading to illness characterized by cough and sore throat. Other studies that challenged via intranasal mucosal exposure observed high doses required for similarly symptomatic respiratory illnesses. Analysis of the Evaluating Modes of Influenza Transmission (EMIT) influenza human-challenge transmission trial—of 52 H3N2 inoculated viral donors and 75 sero-susceptible exposed individuals—quantifies airborne transmission and provides context and insight into methodology related to airborne transmission. Advances in aerosol sampling and epidemiologic studies examining the role of masking, and engineering-based air hygiene strategies provide a foundation for understanding risk and directions for new work.

Energy efficiency in large office buildings post-COVID-19 in Europe's top five economies

Since the World Health Organization announced the COVID-19 pandemic, indoor airflows became a synonym for virus super-spreaders and the focus point for the scientific community and professional associations across the globe, disrupting all daily life dimensions. Europe's quick response to control the disease led the REHVA board to address mitigation guidelines, reassessed by each member association's following national specifics. The present study aims to quantify the energy consumption and CO₂ emissions of "large office" buildings in top-five European economies under the COVID-19 guidelines under the post-pandemic telework forecast. Methodology resorted to a standard model under Building Energy Simulation assessment to compare prior and posterior scenarios. The latter displays a tendency to increase energy and CO₂ emissions in all locations, in the first form 10.18% (Rome) to 69.48% (Paris); and second 5.80% (Rome) and 120.61% (Paris), which will affect national energy production and imports, urban pollution and business competitiveness. On a different scope, future HVAC guidelines need to address the incoming figures, particularly in highly dense urban areas. Also, to comply with the goals set by the Paris Accord.

The Energy Efficiency Post-COVID-19 in China’s Office Buildings

China promptly took the leading step to mitigate the spread of COVID-19, producing the first scientific guidelines assuming health above energy consumption and significantly changing HVAC/AHU operation. The research intended to fulfill the gap by measuring the impact of the guidelines on energy use intensity, CO2 emissions, and energy operation costs related to workplaces. The guidelines are long-term sector and industry trends following occupants’ health and safety concerns, and today they are applied to nursing homes. The research extended the study to post-COVID-19 scenarios by crossing those settings with published reports on telework predictions. The methodology resorts to Building Energy Simulation software to assess the Chinese standard large office building on 8 climate zones and 17 subzones between pre- and post-COVID-19 scenarios under those guidelines. The outcomes suggest an upward trend in energy use intensity (11.70–12.46%), CO2 emissions (11.13–11.76%), and costs (9.37–9.89%) for buildings located in “warm/mixed” to “subarctic” climates, especially in colder regions with high heating demands. On the other hand, the figures for “very hot” to “hot/warm” climates lower the energy use intensity (14.76–15.47%), CO2 emissions (9%), and costs (9.64–9.77%).

Inactivation of Pathogens in Air Using Ultraviolet Direct Irradiation Below Exposure Limits

A method is described for inactivation of pathogens, especially airborne pathogens, using ultraviolet (UV) radiation emitted directly into occupied spaces and exposing occupants to a dose below the accepted actinic exposure limit (EL). This method is referred to as direct irradiation below exposure limits, or DIBEL. It is demonstrated herein that low-intensity UV radiation below exposure limits can achieve high levels of equivalent air changes per hour (ACHeq) and can be an effective component of efforts to combat airborne pathogens such as the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19). An ACHeq of 4 h-¹ is presently achievable over a continuous 8 h period for the SARS-CoV-2 virus with UV-C light-emitting diodes (LEDs) having peak wavelength at 275 nm, and future improvements in LED technology and optics are anticipated to enable improvements up to 150 h-¹ in the coming decade. For example, the actinic EL is 60 J/m² at 254 nm, and human coronaviruses, including SARS-CoV-2, have a UV dose required for 90 % inactivation of about 5 J/m² at 254 nm. Irradiation by 254 nm UV-C at the EL is expected to provide 90 % inactivation of these organisms in air in about 40 min when the UV-C is delivered at a constant irradiance over 8 h, or in about 5 min if the UV-C is delivered at a constant irradiance over 1 h. Since the irradiation is continuous, the inactivation of initial contaminants accumulates to 99 % and then 99.9 %, and it also immediately begins inactivating any newly introduced (e.g., exhaled) pathogens at the same rate throughout the 8 h period. The efficacy for inactivating airborne pathogens with DIBEL may be expressed in terms of ACHeq, which may be compared with conventional ventilation-based methods for air disinfection. DIBEL may be applied in addition to other disinfection methods, such as upper room UV germicidal irradiation, and mechanical ventilation and filtration. The ACHeq of the separate methods is additive, providing enhanced cumulative disinfection rates. Conventional air disinfection technologies have typical ACHeq values of about 1 h-¹ to 5 h-¹ and maximum practical values of about 20 h-¹. UV-C DIBEL currently provides ACHeq values that are typically about 1 h-¹ to 10 h-¹, thus either complementing, or potentially substituting for, conventional technologies. UV-C DIBEL protocols are forecast herein to evolve to >100 ACHeq in a few years, potentially surpassing conventional technologies. UV-A (315 nm to 400 nm) and/or UV-C (100 nm to 280 nm) DIBEL is also efficacious at inactivating pathogens on surfaces. The relatively simple installation, low acquisition and operating costs, and unobtrusive aesthetic of DIBEL using UV LEDs contribute value in a layered, multi-agent disinfection strategy.

Control of airborne infectious disease in buildings: Evidence and research priorities

The evolution of SARS-CoV-2 virus has resulted in variants likely to be more readily transmitted through respiratory aerosols, underscoring the increased potential for indoor environmental controls to mitigate risk. Use of tight-fitting face masks to trap infectious aerosol in exhaled breath and reduce inhalation exposure to contaminated air is of critical importance for disease control. Administrative controls including the regulation of occupancy and interpersonal spacing are also important, while presenting social and economic challenges. Indoor engineering controls including ventilation, exhaust, air flow control, filtration, and disinfection by germicidal ultraviolet irradiation can reduce reliance on stringent occupancy restrictions. However, the effects of controls-individually and in combination-on reducing infectious aerosol transfer indoors remain to be clearly characterized to the extent needed to support widespread implementation by building operators. We review aerobiologic and epidemiologic evidence of indoor environmental controls against transmission and present a quantitative aerosol transfer scenario illustrating relative differences in exposure at close-interactive, room, and building scales. We identify an overarching need for investment to implement building controls and evaluate their effectiveness on infection in well-characterized and real-world settings, supported by specific, methodological advances. Improved understanding of engineering control effectiveness guides implementation at scale while considering occupant comfort, operational challenges, and energy costs.

The vaccination threshold for SARS-CoV-2 depends on the indoor setting and room ventilation

BACKGROUND

Effective vaccines are now available for SARS-CoV-2 in the 2nd year of the COVID-19 pandemic, but there remains significant uncertainty surrounding the necessary vaccination rate to safely lift occupancy controls in public buildings and return to pre-pandemic norms. The aim of this paper is to estimate setting-specific vaccination thresholds for SARS-CoV-2 to prevent sustained community transmission using classical principles of airborne contagion modeling. We calculated the airborne infection risk in three settings, a classroom, prison cell block, and restaurant, at typical ventilation rates, and then the expected number of infections resulting from this risk at varying percentages of occupant immunity.

RESULTS

We estimate the setting-specific immunity threshold for control of wild-type SARS-CoV-2 to range from a low of 40% for a mechanically ventilation classroom to a high of 85% for a naturally ventilated restaurant.

CONCLUSIONS

If vaccination rates are limited to a theoretical minimum of approximately two-thirds of the population, enhanced ventilation above minimum standards for acceptable air quality is needed to reduce the frequency and severity of SARS-CoV-2 superspreading events in high-risk indoor environments.

Patterns of SARS-CoV-2 aerosol spread in typical classrooms

Although current industry guidelines to control the spread of aerosols such as SARS-CoV-2 (COVID-19) have adopted a six-foot (~1.8 m) spacing between individuals indoors, recent evidence suggests that longer range spread is also responsible for infections in public spaces. The vehicle for long-range spread is smaller (<5 μm) droplets or particles, termed bio-aerosols, or aerosols for short, which have a large surface area to volume ratio such that aerodynamic drag is much larger than gravity forces. The aerosols remain suspended in air for extended time periods, and they essentially move with air currents. Prediction of the danger to occupants in a closed room when exposed to an infected individual requires knowledge of the period of exposure and the concentration level of aerosols in the breathing zone of an occupant. To obtain an estimate of the concentration level, a common assumption is well-mixed conditions within an interior space. This is obtained from a mass balance between the level of aerosol produced by an infected individual along with the airflow rate into and out of the entire space. In this work, we use computational fluid dynamics, compared with experimental results in several cases, to explore the aerosol concentration distribution in a typical classroom for several common conditions and compare these results to the well-mixed assumption. We use a tracer gas to approximately simulate the flow and dispersion of the aerosol-air mixture. The two ventilation systems examined, ceiling diffusers and open windows, yield average concentrations at occupant breathing level 50 % greater than the well mixed case, and some scenarios yield concentrations that are 150 % greater than the well mixed concentration at specific breathing-level locations. Of particular concern are two conditions: horizontal air flow from an open window in line with a row of seating and, second, an infected individual seated near a sealed cold window. For the former, conditions are improved if a baffle is placed inside the open window to direct the air toward the floor, creating a condition similar to displacement ventilation. In the latter, the cold air flowing down along the cold window recirculates aerosols back into the breathing zone. Adding window covers or a portable heater below the window surface will moderate this condition.

COVID-19: The impact in US high-rise office buildings energy efficiency

The COVID-19 pandemic, through stay-at-home orders, forced rapid changes to social human behavior and interrelations, targeting the work environments to protect workers and users. Rapidly, global organizations, US associations, and professionals stepped in to mitigate the virus's spread in buildings' living and work environments. The institutions proposed new HVAC settings without efficiency concerns, as improved flow rates and filtering for irradiation, humidity, and temperature. Current literature consensually predicted an increase in energy consumption due to new measures to control the SARS-CoV-2 spread. The research team assumed the effort of validating the prior published outcomes, applied to US standardized high-rise office buildings, as defined and set by the key entities in the field, by resorting to a methodology based on software energy analysis. The study compares a standard high-rise office building energy consumption, CO₂ emissions and operations costs in nine US climate zones - from 0 to 8, south to north latitudes, respectively -, assessed in the most populated cities, between the previous and post COVID-19 scenarios. The outcomes clarify the gathered knowledge, explaining that climate zones above mixed-humid type tend to increase relative energy use intensity by 21.72%, but below that threshold the zones decrease relative energy use intensity by 11.92%.

Addressing COVID-19 contagion through the HVAC systems by reviewing indoor airborne nature of infectious microbes: Will an innovative air recirculation concept provide a practical solution?

As the world continues to grapple with the reality of coronavirus disease, global research communities are racing to develop practical solutions to adjust to the new challenges. One such challenge is the control of indoor air quality in the COVID-19 era and beyond. Since COVID-19 became a global pandemic, the "super spread" of the virus has continued to amaze policymakers despite measures put in place by public health officials to sensitize the general public on the need for social distancing, personal hygiene, etc. In this work, we have reviewed the literature to demonstrate, by investigating the historical and present circumstances, that indoor spread of infectious diseases may be assisted by the conditions of the HVAC systems. While little consideration has been given to the possibility of indoor airborne transmission of the virus, the available reports have demonstrated that the virus, with average aerodynamic diameter up to 80-120 nm, is viable as aerosol in indoor atmosphere for more than 3 h, and its spread may be assisted by the HVAC systems. Having reviewed the vulnerability of the conventional ventilation systems, we recommend innovative air circulation concept supported by the use of UVGI in combination with nanoporous air filter to combat the spread of SARS-CoV-2 and other harmful microbes in enclosed spaces.

The efficacy of ultraviolet light-emitting technology against coronaviruses: a systematic review

The ongoing pandemic of COVID-19 has underlined the importance of adopting effective infection prevention and control (IPC) measures in hospital and community settings. Ultraviolet (UV)-based technologies represent promising IPC tools: their effective application for sanitation has been extensively evaluated in the past but scant, heterogeneous and inconclusive evidence is available on their effect on SARS-CoV-2 transmission. With the aim of pooling the available evidence on the efficacy of UV technologies against coronaviruses, we conducted a systematic review following PRISMA guidelines, searching Medline, Embase and the Cochrane Library, and the main clinical trials' registries (WHO ICTRP, ClinicalTrials.gov, Cochrane and EU Clinical Trial Register). Quantitative data on studies' interventions were summarized in tables, pooled by different coronavirus species and strain, UV source, characteristics of UV light exposure and outcomes. Eighteen papers met our inclusion criteria, published between 1972 and 2020. Six focused on SARS-CoV-2, four on SARS-CoV-1, one on MERS-CoV, three on seasonal coronaviruses, and four on animal coronaviruses. All were experimental studies. Overall, despite wide heterogenicity within included studies, complete inactivation of coronaviruses on surfaces or aerosolized, including SARS-CoV-2, was reported to take a maximum exposure time of 15 min and to need a maximum distance from the UV emitter of up to 1 m. Advances in UV-based technologies in the field of sanitation and their proved high virucidal potential against SARS-CoV-2 support their use for IPC in hospital and community settings and their contribution towards ending the COVID-19 pandemic. National and international guidelines are to be updated and parameters and conditions of use need to be identified to ensure both efficacy and safety of UV technology application for effective infection prevention and control in both healthcare and non-healthcare settings.

Critical Design Parameters in Design and Efficacy of Upper-Room UVC254 Luminaire Systems: Part I: Overview of Major Parameters and Relationships†

During the current SARS-CoV-2 and tuberculosis global pandemics, public health and infection prevention and control professionals wrestle with cost-effective means to control airborne transmission. One technology recommended by Centers for Disease Control and Prevention and the World Health Organization for lowering indoor concentration of these and other microorganisms and viruses is upper-room ultraviolet 254 nm (UVC254 ) systems. Applying both a material balance as well as some nondimensional parameters developed by Rudnick and First, the impact of several critical parameters and their effect on the fraction of microorganisms surviving UVC254 exposure was evaluated. Vertical airspeed showed a large impact at velocities <0.05 m s-1 but a lesser effect at velocities >0.05 m s-1 . In addition, the efficacy of any upper-room UVC system is influenced greatly by the mean room fluence rate as opposed to a simple volume- or area-based dosing criteria. An alternative UVC254 dosing strategy was developed based on the fluence rate as a function of the UVC254 luminaire output (W) and the square root of the product of the room volume and the ceiling height.

Greater than 3-Log Reduction in Viable Coronavirus Aerosol Concentration in Ducted Ultraviolet-C (UV-C) Systems

Control technologies to inactivate airborne viruses effectively are needed during the ongoing SARS-CoV-2 pandemic, and to guard against airborne transmitted diseases. We demonstrate that sealed UV-C flow reactors operating with fluences near 253 ± 1 nm of 13.9-49.6 mJ cm-2 efficiently inactivate coronaviruses in an aerosol. For measurements, porcine respiratory coronavirus (PRCV) was nebulized in a custom-built, 3.86 m wind tunnel housed in a biosafety level class II facility. The single pass log10 reduction of active coronavirus was in excess of 2.2 at a flow rate of 2439 L min-1 (13.9 mJ cm-2) and in excess of 3.7 (99.98% removal efficiency) at 684 L min-1 (49.6 mJ cm-2). Because virus titers resulting from sampling downstream of the UV-C reactor were below the limit of detection, the true log reduction is likely even higher than measured. Comparison of virus titration results to reverse transcriptase quantitative PCR and measurement of fluorescein concentrations (doped into the nebulized aerosol) reveals that the reduction in viable PRCV is primarily due to UV-C based inactivation, as opposed to physical collection of virus. The results confirm that UV-C flow reactors can efficiently inactivate coronaviruses through incorporation into HVAC ducts or recirculating air purifiers.

An Emphasis on Engineering Controls and Administrative Controls in the Prevention and Control of COVID-19 in an Orthodontic Setting: Thinking Beyond Tomorrow

Introduction: Most of the initial focus in handling COVID-19 had been based on avoiding exposure by refraining from rendering most treatments other than those considered an emergency or urgent. Post-lockdown, with the resumption of most activities, there has been concern over the possibility of transmission scenarios if sufficient care is not taken. The control and prevention of the spread of infections when elimination of exposure is not possible is chiefly achieved through the judicious use of engineering controls and administrative controls in a clinical setting in addition to the standard protocols and transmission-based protocols. True safety lies in being one step ahead. There have been mentions of the possibility that COVID-19 could be opportunistic airborne in its spread, in addition to being spread via saliva, droplets, and contaminated surfaces or objects.

Method: A literature search of PubMed, Google Scholar, Cochrane Library, and advisories released by such organizations as the World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), Ministry of Health and Family Welfare (MOFHW), European Centre for Disease Prevention and Control (ECDC), Chinese Center for Disease Control and Prevention (China CDC), American Dental Association (ADA), Canadian Dental Association (CDA), French National Dentists Association, Dental Council of Belgium, National Health Service, England (NHS UK), National Health Service Scotland (NHS Scotland), and International Society for Infectious Diseases (ISID) was performed, with search parameters aimed at gathering information pertaining to infection control and cross infection control in dental settings as related to orthodontics.

Result: There have been numerous articles and advisories published over the last 20 years, but the main focus has been on safe practices and to an extent on personal protective equipment, with relatively less emphasis on the need for respiratory protection by way of engineering controls and administrative controls. This review highlights the engineering and administrative controls that can be put into effect to make infection control and prevention much more effective.

Conclusion: Any health care facility must be able to prevent, contain, and control infections with no risk of nosocomial infections. For this, an assumption has to be made that every individual in a health care setting is either at risk or a risk, depending on whether the person is infected or not. Meticulous attention to stringent policies of hygiene and infection control and prevention, coupled with suitable supporting engineering and administrative controls, is to be made a standard way of life in such facilities.

Impact of the interferon-γ release assay and glomerular filtration rate on the estimation of active tuberculosis risk before bronchoscopic examinations: a retrospective pilot study

Background

Bronchoscopic examinations are vital to diagnose pulmonary diseases. However, as coughing is triggered during and after the procedure, it is imperative to take measures against nosocomial infections, especially for airborne infections like tuberculosis (TB). The interferon-γ release assay (IGRA) has recently been established as a method to evaluate the infection status of TB. We aimed to ascertain the efficacy of IGRA and clinical findings in estimating the prevalence of active TB before bronchoscopy.

Methods

We obtained IGRA results from 136 inpatients using a QuantiFERON-TB Gold In-Tube test. Bronchoscopy samples were cultured in Mycobacteria Growth indicator tubes and 2% Ogawa solid medium. We evaluated the adjusted effects of multiple clinical variables on active TB status using a logistic regression model. In addition, multiple variables were converted into a decision tree to predict active TB.

Results

Five (3.7%) patients were diagnosed with culture-positive TB, two of whom were simultaneously diagnosed with non-small-cell lung carcinoma or small-cell lung carcinoma. The multivariate analysis suggested the probability of predicting active TB using the IGRA [odds ratio (OR), 72.7; 95% confidence interval (CI), 3.169-1668; P=0.007] and decreased estimated glomerular filtration rate (eGFR) (OR, 0.937; 95% CI, 0.882-0.996; P=0.038) in patients undergoing bronchoscopy. A decision tree validated the use of these two variables to predict active TB.

Conclusions

IGRA test results are useful for predicting active TB before bronchoscopy. This strategy could identify patients who require antibiotic therapy to prevent TB or who are in the active phase of TB.

Environmental factors involved in SARS-CoV-2 transmission: effect and role of indoor environmental quality in the strategy for COVID-19 infection control

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a new zoonotic agent that emerged in December 2019, causes coronavirus disease 2019 (COVID-19). This infection can be spread by asymptomatic, presymptomatic, and symptomatic carriers. SARS-CoV-2 spreads primarily via respiratory droplets during close person-to-person contact in a closed space, especially a building. This article summarizes the environmental factors involved in SARS-CoV-2 transmission, including a strategy to prevent SARS-CoV-2 transmission in a building environment. SARS-CoV-2 can persist on surfaces of fomites for at least 3 days depending on the conditions. If SARS-CoV-2 is aerosolized intentionally, it is stable for at least several hours. SARS-CoV-2 is inactivated rapidly on surfaces with sunlight. Close-contact aerosol transmission through smaller aerosolized particles is likely to be combined with respiratory droplets and contact transmission in a confined, crowded, and poorly ventilated indoor environment, as suggested by some cluster cases. Although evidence of the effect of aerosol transmission is limited and uncertainty remains, adequate preventive measures to control indoor environmental quality are required, based on a precautionary approach, because COVID-19 has caused serious global damages to public health, community, and the social economy. The expert panel for COVID-19 in Japan has focused on the "3 Cs," namely, "closed spaces with poor ventilation," "crowded spaces with many people," and "close contact." In addition, the Ministry of Health, Labour and Welfare of Japan has been recommending adequate ventilation in all closed spaces in accordance with the existing standards of the Law for Maintenance of Sanitation in Buildings as one of the initial political actions to prevent the spread of COVID-19. However, specific standards for indoor environmental quality control have not been recommended and many scientific uncertainties remain regarding the infection dynamics and mode of SARS-CoV-2 transmission in closed indoor spaces. Further research and evaluation are required regarding the effect and role of indoor environmental quality control, especially ventilation.

Environmental factors involved in SARS-CoV-2 transmission: effect and role of indoor environmental quality in the strategy for COVID-19 infection control

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a new zoonotic agent that emerged in December 2019, causes coronavirus disease 2019 (COVID-19). This infection can be spread by asymptomatic, presymptomatic, and symptomatic carriers. SARS-CoV-2 spreads primarily via respiratory droplets during close person-to-person contact in a closed space, especially a building. This article summarizes the environmental factors involved in SARS-CoV-2 transmission, including a strategy to prevent SARS-CoV-2 transmission in a building environment. SARS-CoV-2 can persist on surfaces of fomites for at least 3 days depending on the conditions. If SARS-CoV-2 is aerosolized intentionally, it is stable for at least several hours. SARS-CoV-2 is inactivated rapidly on surfaces with sunlight. Close-contact aerosol transmission through smaller aerosolized particles is likely to be combined with respiratory droplets and contact transmission in a confined, crowded, and poorly ventilated indoor environment, as suggested by some cluster cases. Although evidence of the effect of aerosol transmission is limited and uncertainty remains, adequate preventive measures to control indoor environmental quality are required, based on a precautionary approach, because COVID-19 has caused serious global damages to public health, community, and the social economy. The expert panel for COVID-19 in Japan has focused on the "3 Cs," namely, "closed spaces with poor ventilation," "crowded spaces with many people," and "close contact." In addition, the Ministry of Health, Labour and Welfare of Japan has been recommending adequate ventilation in all closed spaces in accordance with the existing standards of the Law for Maintenance of Sanitation in Buildings as one of the initial political actions to prevent the spread of COVID-19. However, specific standards for indoor environmental quality control have not been recommended and many scientific uncertainties remain regarding the infection dynamics and mode of SARS-CoV-2 transmission in closed indoor spaces. Further research and evaluation are required regarding the effect and role of indoor environmental quality control, especially ventilation.

Considerations for Oral and Maxillofacial Surgeons in COVID-19 Era: Can We Sustain the Solutions to Keep Our Patients and Healthcare Personnel Safe?

Several uncertainties exist regarding how we will conduct our clinical, didactic, business, and social activities as the coronavirus disease 2019 (COVID-19) global pandemic abates and social distancing guidelines are relaxed. We anticipate changes in how we interact with our patients and other providers, how patient workflow is designed, the methods used to conduct our teaching sessions, and how we perform procedures in different clinical settings. The objective of the present report is to review some of the changes to consider in the clinical and academic oral and maxillofacial surgery workflow and, allow for a smoother transition, with less risk to our patients and healthcare personnel. New infection control policies should be strictly enforced and monitored in all clinical and nonclinical settings, with an overall goal to decrease the risk of exposure and transmission. Screening for COVID-19 symptoms, testing when indicated, and establishing the epidemiologic linkage will be crucial to containing and preventing new COVID-19 cases until a vaccine or an alternate solution is available. Additionally, the shortage of essential supplies such as drugs and personal protective equipment, the design and ventilation of workspaces and waiting areas, the increase in overhead costs, and the possible absence of staff, if quarantine is necessary, must be considered. This shift in our workflow and patient care paths will likely continue in the short-term at least through 2021 or the next 12 to 24 months. Thus, we must prioritize surgery, balancing patient preferences and healthcare personnel risks. We have an opportunity now to make changes and embrace telemedicine and other collaborative virtual platforms for teaching and clinical care. It is crucial that we maintain COVID-19 awareness, proper surveillance in our microenvironments, good clinical judgment, and ethical values to continue to deliver high-quality, economical, and accessible patient care.

COVID-19 Considerations in Pediatric Dentistry

KNOWLEDGE TRANSFER STATEMENT

This article aims to acquaint clinicians treating pediatric patients with COVID-19 hazards and delineate the steps required for minimizing cross-infection in case of providing emergency treatment to children in dental offices.

Preventing Transmission of Mycobacterium Tuberculosis-A Refocused Approach

Traditional tuberculosis (TB) infection control focuses on the known patient with TB, usually on appropriate treatment. A refocused, intensified TB infection control approach is presented. Combined with active case finding and rapid molecular diagnostics, an approach called FAST is described as a convenient way to call attention to the untreated patient. Natural ventilation is the mainstay of air disinfection in much of the world. Germicidal ultraviolet technology is the most sustainable approach to air disinfection under resource-limited conditions. Testing and treatment of latent TB infection works to prevent reactivation but requires greater risk targeting in both low- and high-risk settings.

Potential benefits and harms of the use of UV radiation in transmission of tuberculosis in South African health facilities

The incidence and prevalence of transmitted Mycobacterium tuberculosis have risen very rapidly in modern society. Environmental control measure such as ultraviolet radiation has been introduced in various health care facilities. This preventative measure has been extensively explored in the medical, legislative and public forums. However, the guidelines and manufacturer's claims have created controversies, in terms of prevention of cross-transmission of M. tuberculosis in health care facilities. In this article, the authors reviewed the overall benefits and harms associated with the use of ultraviolet radiation in the prevention of M. tuberculosis transmission. The author concluded that there are still existing gaps in proving beyond any reasonable doubt that ultraviolet radiations absolutely prevent the spread of M. tuberculosis in South African health facilities.

Improving natural ventilation in hospital waiting and consulting rooms to reduce nosocomial tuberculosis transmission risk in a low resource setting

Background

TB transmission in healthcare facilities is an important public health problem, especially in the often-overcrowded settings of HIV treatment scale-up. The problem is compounded by the emergence of drug resistant TB. Natural ventilation is a low-cost environmental control measure for TB infection control where climate permits that is suited to many different areas in healthcare facilities. There are no published data on the effect of simple structural modifications to existing hospital infrastructure to improve natural ventilation and reduce the risk of nosocomial TB transmission.

The purpose of this study was to measure the effect of simple architectural modifications to existing hospital waiting and consulting rooms in a low resource setting on (a) improving natural ventilation and (b) reducing modelled TB transmission risk.

Methods

Room ventilation was measured pre- and post-modification using a carbon dioxide tracer-gas technique in four waiting rooms and two consulting rooms in two hospitals in Lima, Peru. Modifications included additional windows for cross-ventilation (n = 2 rooms); removing glass from unopenable windows (n = 2); creation of an open skylight (n = 1); re-building a waiting-room in the open air (n = 1). Changes in TB transmission risk for waiting patients, or healthcare workers in consulting rooms, were estimated using mathematical modelling.

Results

As a result of the infrastructure modifications, room ventilation in the four waiting rooms increased from mean 5.5 to 15; 11 to 16; 10 to 17; and 9 to 66 air-changes/hour respectively; and in the two consulting rooms from mean 3.6 to 17; and 2.7 to 12 air-changes/hour respectively. There was a median 72% reduction (inter-quartile range 51–82%) in calculated TB transmission risk for healthcare workers or waiting patients. The modifications cost <US$75 in four rooms, and US$1000 and US$7000 in the remaining two rooms.

Conclusions

Simple modifications to existing hospital infrastructure considerably increased natural ventilation, and greatly reduced modelled TB transmission risk at little cost.

Cough Frequency During Treatment Associated With Baseline Cavitary Volume and Proximity to the Airway in Pulmonary TB

BACKGROUND

Cough frequency, and its duration, is a biomarker that can be used in low-resource settings without the need of laboratory culture and has been associated with transmission and treatment response. Radiologic characteristics associated with increased cough frequency may be important in understanding transmission. The relationship between cough frequency and cavitary lung disease has not been studied.

METHODS

We analyzed data in 41 adults who were HIV negative and had culture-confirmed, drug-susceptible pulmonary TB throughout treatment. Cough recordings were based on the Cayetano Cough Monitor, and sputum samples were evaluated using microscopic observation drug susceptibility broth culture; among culture-positive samples, bacillary burden was assessed by means of time to positivity. CT scans were analyzed by a US-board-certified radiologist and a computer-automated algorithm. The algorithm evaluated cavity volume and cavitary proximity to the airway. CT scans were obtained within 1 month of treatment initiation. We compared small cavities (≤ 7 mL) and large cavities (> 7 mL) and cavities located closer to (≤ 10 mm) and farther from (> 10 mm) the airway to cough frequency and cough cessation until treatment day 60.

RESULTS

Cough frequency during treatment was twofold higher in participants with large cavity volumes (rate ratio [RR], 1.98; P = .01) and cavities located closer to the airway (RR, 2.44; P = .001). Comparably, cough ceased three times faster in participants with smaller cavities (adjusted hazard ratio [HR], 2.89; P = .06) and those farther from the airway (adjusted HR, 3.61;, P = .02). Similar results were found for bacillary burden and culture conversion during treatment.

CONCLUSIONS

Cough frequency during treatment is greater and lasts longer in patients with larger cavities, especially those closer to the airway.

Dynamics of Cough Frequency in Adults Undergoing Treatment for Pulmonary Tuberculosis

Background

Cough is the major determinant of tuberculosis transmission. Despite this, there is a paucity of information regarding characteristics of cough frequency throughout the day and in response to tuberculosis therapy. Here we evaluate the circadian cycle of cough, cough frequency risk factors, and the impact of appropriate treatment on cough and bacillary load.

Methods

We prospectively evaluated human immunodeficiency virus-negative adults (n = 64) with a new diagnosis of culture-proven, drug-susceptible pulmonary tuberculosis immediately prior to treatment and repeatedly until treatment day 62. At each time point, participant cough was recorded (n = 670) and analyzed using the Cayetano Cough Monitor. Consecutive coughs at least 2 seconds apart were counted as separate cough episodes. Sputum samples (n = 426) were tested with microscopic-observation drug susceptibility broth culture, and in culture-positive samples (n = 252), the time to culture positivity was used to estimate bacillary load.

Results

The highest cough frequency occurred from 1 pm to 2 pm, and the lowest from 1 am to 2 am (2.4 vs 1.1 cough episodes/hour, respectively). Cough frequency was higher among participants who had higher sputum bacillary load (P < .01). Pretreatment median cough episodes/hour was 2.3 (interquartile range [IQR], 1.2-4.1), which at 14 treatment days decreased to 0.48 (IQR, 0.0-1.4) and at the end of the study decreased to 0.18 (IQR, 0.0-0.59) (both reductions P < .001). By 14 treatment days, the probability of culture conversion was 29% (95% confidence interval, 19%-41%).

Conclusions

Coughs were most frequent during daytime. Two weeks of appropriate treatment significantly reduced cough frequency and resulted in one-third of participants achieving culture conversion. Thus, treatment by 2 weeks considerably diminishes, but does not eliminate, the potential for airborne tuberculosis transmission.

Comparison of UV C Light and Chemicals for Disinfection of Surfaces in Hospital Isolation Units

Objective.

To determine the bactericidal effect on surfaces of ceiling- and wall-mounted UV C (UVC) light (wavelength, 254 nm) in isolation units, compared with standard hospital environmental cleaning and chemical disinfection during final disinfection after patients are treated for infections.

Design.

Microbial samples were obtained from surfaces in isolation units (patient room, anteroom, and bathroom) before and after irradiation with UVC, chloramine disinfection, and standard hospital environmental cleaning. Samples were tested using standard contact plates.

Setting.

Four identical, negative air-pressure isolation units (patient room, anteroom, and bathroom) with a defined number of ceiling-and wall-mounted UVC light units. The UVC distribution was monitored in one isolation unit after irradiation for approximately 40 minutes, corresponding to doses ranging from 160 J/m2in a shadowed area to 19,230 J/m2at the mostly highly exposed site (which is high enough to inactivate most bacterial organisms, including spores).

Results.

UVC disinfection significantly reduced the number of bacteria on surfaces directly or indirectly exposed to UVC to a very low number, as did 5% chloramine disinfection alone (P<.001 for both). Completely shadowed areas in the isolation unit (eg, the bed rail, lockers, and mattresses) still required disinfection by chemicals.

Conclusion.

Disinfection with UVC light may significantly reduce environmental bacterial contamination and thereby protect the next patient housed in an isolation room. UVC disinfection may not be used alone but is a good addition to chemical disinfection.

Indoor environmental control of tuberculosis and other airborne infections

Tuberculosis (TB) remains the airborne infection of global importance, although many environmental interventions to control TB apply to influenza and other infections with airborne potential. This review focuses on the global problem and the current state of available environmental interventions. TB transmission is facilitated in overcrowded, poorly ventilated congregate settings, such as hospitals, clinics, prisons, jails, and refugee camps. The best means of TB transmission control is source control- to identify unsuspected infectious cases and to promptly begin effective therapy. However, even with active case finding and rapid diagnostics, not every unsuspected case will be identified, and environmental control measures remain the next intervention of choice. Natural ventilation is the main means of air disinfection and has the advantage of wide availability, low cost, and high efficacy-under optimal conditions. It is usually not applicable all year in colder climates and may not be effective when windows are closed on cold nights in warm climates, for security, and for pest control. In warm climates, windows may be closed when air conditioning is installed for thermal comfort. Although mechanical ventilation, if properly installed and maintained, can provide adequate air disinfection, it is expensive to install, maintain, and operate. The most cost-effective way to achieve high levels of air disinfection is upper room germicidal irradiation. The safe and effective application of this poorly defined intervention is now well understood, and recently published evidence-based application guidelines will make implementation easier.

The transmission of Mycobacterium tuberculosis in high burden settings

Unacceptable levels of Mycobacterium tuberculosis transmission are noted in high burden settings and a renewed focus on reducing person-to-person transmission in these communities is needed. We review recent developments in the understanding of airborne transmission. We outline approaches to measure transmission in populations and trials and describe the Wells-Riley equation, which is used to estimate transmission risk in indoor spaces. Present research priorities include the identification of effective strategies for tuberculosis infection control, improved understanding of where transmission occurs and the transmissibility of drug-resistant strains, and estimates of the effect of HIV and antiretroviral therapy on transmission dynamics. When research is planned and interventions are designed to interrupt transmission, resource constraints that are common in high burden settings-including shortages of health-care workers-must be considered.

Ultraviolet germicidal irradiation susceptibility of methicillin-resistant Staphylococcus aureus compared with methicillin-susceptible S. aureus

Antibiotic misuse and overuse in both the healthcare and agricultural fields have dramatically increased the prevalence of antibiotic resistance in human pathogens. Two strains of methicillin-resistant Staphylococcus aureus (MRSA) (ATCC 43330 and a wild-type) and 1 strain of methicillin-susceptible S. aureus (ATCC 25923) were challenged (9 runs in triplicate) in a preliminary study with ultraviolet germicidal irradiation (UVGI) doses ranging from 0.25 to 3.00 mJ/cm(2). The mean percent kill was calculated for each strain when compared with the control plates (no exposure to UVGI). Then, each strain was challenged (22 runs in triplicate) with UVGI doses of 2.00, 2.50, and 3.00 mJ/cm(2). The results suggest a difference between the doses required to disinfect surfaces with each strain. Assuming a standard error rate of α = 0.05, there was a significant difference in variance between the MRSA (ATCC 43330 and wild type) strains and the S. aureus (ATCC 25923) methicillin-susceptible strain.

Institutional Tuberculosis Transmission. Controlled Trial of Upper Room Ultraviolet Air Disinfection: A Basis for New Dosing Guidelines

RATIONALE

Transmission is driving the global tuberculosis epidemic, especially in congregate settings. Worldwide, natural ventilation is the most common means of air disinfection, but it is inherently unreliable and of limited use in cold climates. Upper room germicidal ultraviolet (UV) air disinfection with air mixing has been shown to be highly effective, but improved evidence-based dosing guidelines are needed.

OBJECTIVES

To test the efficacy of upper room germicidal air disinfection with air mixing to reduce tuberculosis transmission under real hospital conditions, and to define the application parameters responsible as a basis for proposed new dosing guidelines.

METHODS

Over an exposure period of 7 months, 90 guinea pigs breathed only untreated exhaust ward air, and another 90 guinea pigs breathed only air from the same six-bed tuberculosis ward on alternate days when upper room germicidal air disinfection was turned on throughout the ward.

MEASUREMENTS AND MAIN RESULTS

The tuberculin skin test conversion rates (>6 mm) of the two chambers were compared. The hazard ratio for guinea pigs in the control chamber converting their skin test to positive was 4.9 (95% confidence interval, 2.8-8.6), with an efficacy of approximately 80%.

CONCLUSIONS

Upper room germicidal UV air disinfection with air mixing was highly effective in reducing tuberculosis transmission under hospital conditions. These data support using either a total fixture output (rather than electrical or UV lamp wattage) of 15-20 mW/m(3) total room volume, or an average whole-room UV irradiance (fluence rate) of 5-7 μW/cm(2), calculated by a lighting computer-assisted design program modified for UV use.

Reduction and characterization of bioaerosols in a wastewater treatment station via ventilation

Bioaerosols from wastewater treatment processes are a significant subgroup of atmospheric aerosols. In the present study, airborne microorganisms generated from a wastewater treatment station (WWTS) that uses an oxidation ditch process were diminished by ventilation. Conventional sampling and detection methods combined with cloning/sequencing techniques were applied to determine the groups, concentrations, size distributions, and species diversity of airborne microorganisms before and after ventilation. There were 3021 ± 537 CFU/m³ of airborne bacteria and 926 ± 132 CFU/m³ of airborne fungi present in the WWTS bioaerosol. Results showed that the ventilation reduced airborne microorganisms significantly compared to the air in the WWTS. Over 60% of airborne bacteria and airborne fungi could be reduced after 4 hr of air exchange. The highest removal (92.1% for airborne bacteria and 89.1% for fungi) was achieved for 0.65-1.1 μm sized particles. The bioaerosol particles over 4.7 μm were also reduced effectively. Large particles tended to be lost by gravitational settling and small particles were generally carried away, which led to the relatively easy reduction of bioaerosol particles 0.65-1.1 μm and over 4.7 μm in size. An obvious variation occurred in the structure of the bacterial communities when ventilation was applied to control the airborne microorganisms in enclosed spaces.

Using computational fluid dynamics modeling to evaluate the design of hospital ultraviolet germicidal irradiation systems for inactivating airborne mycobacteria

This research was conducted to evaluate the design of hospital ultraviolet germicidal irradiation (UVGI) systems and to assess their effectiveness for inactivating airborne mycobacteria. A computational fluid dynamics (CFD) model was developed and tested by simulating previous experiments measuring the effectiveness of a lab-based UVGI system. Model testing showed reasonable agreement with experimental measurements. The model captured trends similar to the experiments: Effectiveness of an upper-room UVGI system is higher when there is no ventilation compared with when there is ventilation, and wintertime ventilation conditions can markedly decrease the performance of an upper-room UVGI system. The CFD model was then applied to evaluate the design of three hospital patient rooms. A patient and an exam room with upper-room UVGI systems, and a patient room with an exhaust duct system were studied. Results showed that one of the UVGI systems was not very effective, due to the very efficient ventilation design. The other two configurations were reasonably to very effective at inactivating airborne mycobacteria. The most effective application was the one in which the room air-exchange rate was very low. CFD modeling can be useful for assessing whether hospital UVGI installations and ventilation systems are effective for infection control.

Aerobiology and its role in the transmission of infectious diseases

Aerobiology plays a fundamental role in the transmission of infectious diseases. As infectious disease and infection control practitioners continue employing contemporary techniques (e.g., computational fluid dynamics to study particle flow, polymerase chain reaction methodologies to quantify particle concentrations in various settings, and epidemiology to track the spread of disease), the central variables affecting the airborne transmission of pathogens are becoming better known. This paper reviews many of these aerobiological variables (e.g., particle size, particle type, the duration that particles can remain airborne, the distance that particles can travel, and meteorological and environmental factors), as well as the common origins of these infectious particles. We then review several real-world settings with known difficulties controlling the airborne transmission of infectious particles (e.g., office buildings, healthcare facilities, and commercial airplanes), while detailing the respective measures each of these industries is undertaking in its effort to ameliorate the transmission of airborne infectious diseases.

Antibiotic resistance acquired through a DNA damage-inducible response in Acinetobacter baumannii

Acinetobacter baumannii is an emerging nosocomial, opportunistic pathogen that survives desiccation and quickly acquires resistance to multiple antibiotics. Escherichia coli gains antibiotic resistances by expressing genes involved in a global response to DNA damage. Therefore, we asked whether A. baumannii does the same through a yet undetermined DNA damage response akin to the E. coli paradigm. We found that recA and all of the multiple error-prone DNA polymerase V (Pol V) genes, those organized as umuDC operons and unlinked, are induced upon DNA damage in a RecA-mediated fashion. Consequently, we found that the frequency of rifampin-resistant (Rif(r)) mutants is dramatically increased upon UV treatment, alkylation damage, and desiccation, also in a RecA-mediated manner. However, in the recA insertion knockout strain, in which we could measure the recA transcript, we found that recA was induced by DNA damage, while uvrA and one of the unlinked umuC genes were somewhat derepressed in the absence of DNA damage. Thus, the mechanism regulating the A. baumannii DNA damage response is likely different from that in E. coli. Notably, it appears that the number of DNA Pol V genes may directly contribute to desiccation-induced mutagenesis. Sequences of the rpoB gene from desiccation-induced Rif(r) mutants showed a signature that was consistent with E. coli DNA polymerase V-generated base-pair substitutions and that matched that of sequenced A. baumannii clinical Rif(r) isolates. These data strongly support an A. baumannii DNA damage-inducible response that directly contributes to antibiotic resistance acquisition, particularly in hospitals where A. baumannii desiccates and tenaciously survives on equipment and surfaces.

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

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

Surgical face masks worn by patients with multidrug-resistant tuberculosis: impact on infectivity of air on a hospital ward

RATIONALE

Drug-resistant tuberculosis transmission in hospitals threatens staff and patient health. Surgical face masks used by patients with tuberculosis (TB) are believed to reduce transmission but have not been rigorously tested.

OBJECTIVES

We sought to quantify the efficacy of surgical face masks when worn by patients with multidrug-resistant TB (MDR-TB).

METHODS

Over 3 months, 17 patients with pulmonary MDR-TB occupied an MDR-TB ward in South Africa and wore face masks on alternate days. Ward air was exhausted to two identical chambers, each housing 90 pathogen-free guinea pigs that breathed ward air either when patients wore surgical face masks (intervention group) or when patients did not wear masks (control group). Efficacy was based on differences in guinea pig infections in each chamber.

MEASUREMENTS AND MAIN RESULTS

Sixty-nine of 90 control guinea pigs (76.6%; 95% confidence interval [CI], 68-85%) became infected, compared with 36 of 90 intervention guinea pigs (40%; 95% CI, 31-51%), representing a 56% (95% CI, 33-70.5%) decreased risk of TB transmission when patients used masks.

CONCLUSIONS

Surgical face masks on patients with MDR-TB significantly reduced transmission and offer an adjunct measure for reducing TB transmission from infectious patients.

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

Objective

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

Methods

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

Results

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

Conclusion

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

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

OBJECTIVE

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

STUDY DESIGN

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

RESULT

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

CONCLUSION

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

A new mathematical model for irradiance field prediction of upper-room ultraviolet germicidal systems

There has been an increasing interest in the use of upper-room ultraviolet germicidal irradiation (UVGI) system because of its proven disinfection effect for airborne microorganisms. To better design and explore further potential applications of UVGI systems, it is of critical importance to predict the spatial UV intensity in enclosures. In this paper, we developed a new mathematical model to predict spatial radiation intensity for upper-room ultraviolet germicidal irradiation systems. The detail geometries of the lamp and the reflector were removed and replaced by introducing a fictitious irradiation surface near louver slots. The view factor approach was applied to evaluate the UV irradiance in a three-dimensional space with different louver configurations. With this approach no detail meshing of the fixture is required and this leads to significant simplification of the entire systems from modeling perspectives. To validate the model, experiments were performed in a full-scale environmental controlled chamber in which one UVGI fixture was mounted on a sidewall. The UV irradiance was measured by a radiometer. The results predicted by the present model agree very well with the experimental measurements. Factors affect the accuracy of the model was also discussed.

Removal of airborne microorganisms emitted from a wastewater treatment oxidation ditch by adsorption on activated carbon

Bioaerosol emissions from wastewater and wastewater treatment processes are a significant subgroup of atmospheric aerosols. Most previous work has focused on the evaluation of their biological risks. In this study, however, the adsorption method was applied to reduce airborne microorganisms generated from a pilot scale wastewater treatment facility with oxidation ditch. Results showed adsorption on granule activated carbon (GAC) was an efficient method for the purification of airborne microorganisms. The GAC itself had a maximum adsorption capacity of 2217 CFU/g for airborne bacteria and 225 CFU/g for fungi with a flow rate of 1.50 m3/hr. Over 85% of airborne bacteria and fungi emitted from the oxidation ditch were adsorbed within 80 hr of continuous operation mode. Most of them had a particle size of 0.65-4.7 microm. Those airborne microorganisms with small particle size were apt to be adsorbed. The SEM/EDAX, BET and Boehm's titration methods were applied to analyse the physicochemical characteristics of the GAC. Relationships between GAC surface characteristics and its adsorption performance demonstrated that porous structure, large surface area, and hydrophobicity rendered GAC an effective absorber of airborne microorganisms. Two regenerate methods, ultraviolet irradiation and high pressure vapor, were compared for the regeneration of used activated carbon. High pressure vapor was an effective technique as it totally destroyed the microorganisms adhered to the activated carbon. Microscopic observation was also carried out to investigate original and used adsorbents.