Monday, January 11, 2021

What's REALLY in the Air?

A Study on Hospital Air: Reviewing the Presence of SARS-Cov-2 
By: Dr. Robert L. Bard / Research & Edits by: Lennard M. Gettz

August 13, 2020 - Recent headlines show evidence of Coronavirus pathogens in hospital air supply and air passageways- creating a systemic hazard for the staff and patients under critical care. Reports showing "substantial controversy whether severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can be transmitted through aerosols."[1- Intl. Journal of Infectious Diseases]. 

Excerpt of active study Abstract (posted 8/4) held by Dr. John Lednicky and research team from the University of Florida: "Air samples were collected in the room of two COVID-19 patients, one of whom had an active respiratory infection with a nasopharyngeal (NP) swab positive for SARS-CoV-2 ... those with respiratory manifestations of COVID-19 produce aerosols in the absence of aerosol-generating procedures that contain viable SARS-CoV-2, and these aerosols may serve as a source of transmission of the virus" [1].

Similar studies have been conducted in prior months to support this theory of airborne pathogens in urgent care centers, including one from February 19 through March 2, 2020 by the CDC. A study was performed in a small sample from regions with few confirmed cases (which might not reflect real conditions in outbreak regions where hospitals are operating at full capacity). [3]

As of March 30, 2020, approximately 750,000 cases of coronavirus disease (COVID-19) had been reported globally since December 2019 (1), severely burdening the healthcare system (2). The extremely fast transmission capability of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has aroused concern about its various transmission routes. This study led to 3 conclusions... [3]

Initiatives are in full swing from health departments and hospital safety leaders to advance sanitization measures and decontamination initiatives in hospitals. Agencies indicate that without adequate environmental controls, patients with airborne infectious disases will pose a risk to other patients and healthcare workers. Heating, Ventilation and Air Conditioning (HVAC)  expertise is essential for proper environmental management when planning control of airborne infectious disease outbreaks.   This may include frequent inspection and upgrades of air filtration systems- such as HEPA Filtering and proper discharging of air to the outside (by creating negative room pressure in patient rooms and airflow management). Other initiatives like stepping up hospital safety inspections and advancing disinfecting, and sanitizing measures to include more current technologies like UV-C light disinfection.




HEPA FILTERS (Source: EPA.gov)
HEPA is a type of pleated mechanical air filter. It is an acronym for "high efficiency particulate air [filter]" (as officially defined by the U.S. Dept. of Energy).  This type of air filter can theoretically remove at least 99.97% of dust, pollen, mold, bacteria, and any airborne particles with a size of 0.3 microns (µm). The diameter specification of 0.3 microns responds to the worst case; the most penetrating particle size (MPPS). Particles that are larger or smaller are trapped with even higher efficiency. Using the worst case particle size results in the worst case efficiency rating (i.e. 99.97% or better for all particle sizes).

MERV RATING
Minimum Efficiency Reporting Values, or MERVs, report a filter's ability to capture larger particles between 0.3 and 10 microns (µm).
  • This value is helpful in comparing the performance of different filters
  • The rating is derived from a test method developed by the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) [see www.ashrae.org].
  • The higher the MERV rating the better the filter is at trapping specific types of particles.
  • See complete rating chart from 1-16
Consider using portable air cleaners to supplement increased HVAC system ventilation and filtration. Directing the airflow so that it does not blow directly from one person to another reduces the potential spread of droplets that may contain infectious viruses. Air cleaning may be useful when used along with source control and ventilation, but it is not a substitute for either method. Source control involves removing or decreasing pollutants such as smoke, formaldehye or particles with viruses. The use of air cleaners alone cannot ensure adequate air quality, particularly where significant pollutant sources are present and ventilation is insufficient. See ASHRAE and CDC for more information on air cleaning and filtration and other important engineering controls. [6]

FROM THE MEDICAL FIELD
By: Megan Meller, MS, MPH

I can’t recommend a specific product but want to emphasize the importance of building HVAC systems and the number of air exchanges that take place in a room. Below I’ve included a table that summarizes guidelines from the CDC for air exchanges in various healthcare settings.


When COVID-19 made it’s presence known, we worked closely with our Facility Operations department to ensure that our exam rooms and hospital rooms were meeting these requirements. In some cases, adjusts were needed and were made. We do use HEPA filters throughout our organization which is a fairly standard technology in healthcare. We do use portable filters but only in select departments (e.g. Oncology) and have not added more for COVID-19. HEPA filters in theory are able to capture coronavirus particles but we don’t know how practical this is and I would not rely solely on this to prevent infection. Afterall, COVID-19 spread appears to be primarily occurring via droplets.   It is much easier to maintain centralized units than individual ones. In addition to shoring up our ventilation systems for COVID, we also implemented physical barriers to protect our patients and staff against COVID including: dedicated negative pressure hospital units, respirators, and organizational wide face masking requirements. The key that I want to stress here is the emphasis on ventilation rather than filtration as complementary to other measures such as social distancing and masking.

References: 
1) Viable SARS-CoV-2 in the air of a hospital room with COVID-19 patients
2) Study finds evidence of COVID-19 in air, on hospital surfaces
3) Aerosol and Surface Distribution of Severe Acute Respiratory Syndrome Coronavirus 2 in Hospital Wards, Wuhan, China, 2020 https://wwwnc.cdc.gov/eid/article/26/7/20-0885_article
4) Minesotta Dept of Health (Airborne Infectious Disease Management): 



Oct 7, 2020, Prevention101 conducted an in-depth interview with Ms. Teri Hulett, professional infection prevention consultant and educator. She provided valuable insight on the branch of service supporting standardized safety protocols in the patient care industry. Having started a career in nursing (neonatal ICU) since 1979, Teri transitioned to focus work in infection prevention due to outbreaks in her facility. This discipline became a full-time commitment which she converted into a national program that called on a significant demand due to the current Covid-19 pandemic.

From the Source: 
INFECTION PREVETION STRATEGIES
Teri Hulett, RN, BSN, CIC, FAPIC | www.ipstrategies.org

Infection prevention has become an area of intensified focus in dental offices and physician's offices. Infection prevention in ambulatory surgery centers (ASC) has been on the radar since 2009. Regulatory surveys assess compliance with mandated IP requirements. State surveyors go into facilities on behalf of CMS and make sure that from an infection prevention perspective, they're meeting all the minimum requirements that must be in place. like proper hand hygiene measures (as an example). Is the facility auditing hand hygiene compliance? Is staff education being provided? Is the facility providing facility compliance information back to the staff with identified opportunities for improvement? 

This is where I come into the picture. Effective November 28, 2017 CMS (Centers for Medicare and Medicaid Services) required all long-term care (LTC) facilities to establish an infection prevention and control program (IPCP) to be phased in over 3 years and managed by an infection preventionist.(IP) who has had formal training. In preparation to meet the CMS requirements, I worked with long-term care facilities in Montana and Wyoming, in collaboration with other quality improvement organizations (QIOs), to provide 3-day LTC bootcamps. We walked attendees through the process of developing their program to meet CMS required elements. The IP program is developed based off a risk assessment (RA). We spent time walking attendees through building their program plan template. We helped them identify who they should work with and where to reach out to for the data to include in their plan. We also helped attendees identify where to access additional formal IP training and education. 

With COVID-19, one of the main focuses has been in LTC facilities due to the many deaths experienced in the first three months of COVID-19. LTC settings were not set up to deal with this type of infectious disease. Most LTC facilities do not have negative pressure rooms. Staff were not fit tested and trained on proper use of N95 respirator masks. There were multiple gaps identified in the LTC setting that could not have been planned and prepared for with respect to what we saw with COVID-19. This identified need again provided the opportunity for me to work with facilities in identifying their gaps and developing interventions to prevent transmission and improve both staff and resident safety.

LTC facilities were overwhelmed; there was a lot of transmission and death. They needed help - someone with experience to walk them through what they needed to do, why they needed to do it, and then work with them to implement key interventions specific to COVID-19. We focused on dealing with immediate  issues  key to  halting transmission, like acquiring enough personal protection equipment (PPE) supplies necessary to prevent transmission and resident deaths, and then aid the facility in developing a comprehensive sustainable program comporting infection prevention and control practices.. 

The CDC provides a robust resource of information - tools and guidelines available to all. Regulatory bodies like CMS and Joint Commission use nationally recognized guidelines to survey against. For the facilities we work with, we help them understand what guidelines to follow in developing their programs – writing their policies and procedures. We stress the importance of following nationally recognized, evidence- based guidelines. Many state health departments use the CDC resources to develop state-specific tools, of which some states will then use to develop toolkits accessible to anyone on their state’s website. An example is the Minnesota Department of Health COVID-19 Toolkit. 








UV-C AIR SANITIZING INSTALLED IN HVAC SYSTEMS
Due to the recent pandemic, companies developing this technology are (now) on the fast track to advance UVC installations for a wide range of professional and commercial environments.  Specific testing is currently underway as to the efficacy against SARS-CoV-2 (the virus that causes COVID-19) but historically, systems like those developed by Fresh-Aire UV have been tested and proven effective against pathogens that require even greater UVC dosages.  "Every microorganism requires a specific UVC dosage for inactivation including the novel coronavirus. UV disinfection has been employed for decades in water treatment; these microwatt values have been used for reference to gauge UVC efficiency against a large cross-section of microorganisms. (see complete article)


Epilogue: Straight Answers from the CDC
In our commitment to publish helpful information about innovative solutions, we rely on top health  authorities to provide us with unbiased clarity and technical standards. We inquired about how UV-C Disinfecting technology truly ranked as the future solution to defeating viruses and transmitted diseases. Steve Martin, PhD, an engineer in NIOSH’s Respiratory Health Division provided us with these valuable statements:

Q: Does the CDC see UV-C Disinfecting as the next trend- evolving from chemical spray sanitizing?
A: No.  CDC understands that germicidal UV technologies, including patient room terminal cleaning devices (sometimes called UV robots), can provide enhanced surface disinfection over the use of chemical disinfectants alone. However, UV technologies, as they currently exist, will never replace manual chemical cleaning in healthcare spaces.  While UV can be very efficient at inactivating pathogens on surfaces, UV-C energy cannot substantially penetrate blood and other bodily fluids, or through other simple spills and splashes that occur in the course of patient care, even those that have dried and left residues. Thus, healthcare surfaces need to first be thoroughly cleaned to remove gross contamination before the UV energy can directly impact the surfaces and provide the most disinfection benefit. Then, UV systems that are properly applied can effectively inactivate many of the pathogens that manual cleaning may have left behind.

Q: From an original post on 2016, CDC warned about potential OZONE output from UV.  It has been evident that companies have since been addressing the testing, preventing and validating of ozone output.  Does CDC have enough data on this upgrade?
A: Concerns about UV lamps producing ozone have existed for decades and there have not been any significant “upgrades” since 2016.  There are some UV-C lamps designed specifically to produce ozone.  Ozone-producing lamps generally do not use an internal coating on the glass (or quartz) tube so UV energy at wavelengths below 200 nm (predominantly 185 nm) is emitted from the lamp. These wavelengths are responsible for ozone production.  There is a separate group of UV-C lamps designed specifically not to produce ozone.  This group is the low-pressure mercury vapor lamps used for germicidal ultraviolet (GUV) applications.  GUV lamps have interior coatings to block UV energy at wavelengths below 200 nm from escaping the tube, so ozone is not created. Unfortunately, ozone-producing lamps and GUV lamps of the same type and size can often be powered using the same electrical connectors and electronic drivers (ballasts).  So, it is critical for the end user to choose the proper lamp for their application.  If they choose a typical GUV lamp for a germicidal application, then ozone is not a concern.  If an end user unknowingly chooses an ozone-producing lamp that happens to fit properly into their GUV device, then ozone exposures will happen. CDC always recommends that end users communicate with the UV device manufacturer or a reputable UV system designer when purchasing replacement UV lamps.




Also see Dr. Pierre Kory's Prevention Measures of Airborne Transmission
Ever since the early pandemic, when quite a few healthcare providers got sick, INFECTION CONTROL was really consistent with what you needed in order to operate in a clinical area, whether it's COVID or any other event. The routine mask wearing regular hand-washing and gown donning has gotten us all through.  Based on TONS of epidemiologic data, which shows that the incidence of infection and transmission plummets when you have a certain percentage of people even wearing standard masks. ...If everybody around you is wearing a mask, (as well as you) the dual mask wearing is as good as if one of you had an N95 to protect themselves. And the reason for that is because those tiny droplets that you can inhale are bursts from larger droplets. And if you're wearing any covering the big spindle or the large droplets that emit when you talk, they all get trapped in those standard masks. They're actually quite protective. 




CONTRIBUTORS

ROBERT L. BARD, MD, PC, DABR, FASLMS
Advanced Imaging & Diagnostic Specialist
Dr. Bard received the 2020 nationally acclaimed Ellis Island Award for his lifetime achievement in advanced cancer diagnostic imaging. He co-founded the 9/11 CancerScan program to bring additional diagnostic support to all first responders from Ground Zero. His main practice in midtown, NYC (Bard Diagnostic Imaging- www.CancerScan.com) uses the latest in digital imaging technology and has been also used to help guide biopsies and in many cases, even replicate much of the same reports of a clinical invasive biopsy. Imaging solutions such as high-powered sonograms, Power Doppler Histogram, sonofluoroscopy, 3D/4D image reconstruction and the Power Doppler Histogram  are safe, noninvasive, and do not use ionizing radiation. 

MEGAN MELLER, MS, MPH is an Infection Preventionist with Gundersen Health System based in La Crosse, Wisconsin. From a young age, Megan has been passionate about science and the world of infectious diseases. Megan received her Master of Science in Microbiology at Indiana University-Bloomington where she studied alphavirus replication and her Master of Public Health (MPH) from the University of Wisconsin School of Medicine and Public Health. While working on her MPH, Megan worked closely with Infection Control departments and the communicable disease section at the Wisconsin Department of Health Services. In her current role, Megan is the lead Infection Preventionist for Gundersen’s outpatient departments and works closely with infection control partners located at regional hospitals. Megan is also a media consultant for the Infection Control and Infectious Disease departments and serves as an infection control consultant for numerous organizational groups.  


PIERRE KORY, M.D., M.P.A.
Dr. Kory is Board Certified in Internal Medicine, Critical Care, and Pulmonary Medicine. He served as the Medical Director of the Trauma and Life Support Center at the University of Wisconsin where he was an Associate Professor and the Chief of the Critical Care Service. He is considered a pioneer and national/international expert in the field of Critical Care Ultrasound and is the senior editor of the widely read textbook “Point-of-Care Ultrasound” (winner of the President’s Choice Award for Medical Textbooks from the British Medical Association in 2015).  Most recently, Dr. Kory joined the emergency volunteer team during the early COVID-19 pandemic in NYC at Mount Sinai Beth Israel Medical Center. He is also a founding member of the Front Line COVID-19 Critical Working Group (flccc.net) composed of 5 critical care experts that devised the COVID-19 treatment protocol called MATH+. (www.covid19criticalcare.com/)

AARON ENGEL
Mr Engel is Vice-President of Business Development for Fresh-Aire UV, a global leader in UV disinfection technologies. Aaron has 20 years experience in the design, manufacturing and marketing of UV disinfection systems for domestic and international applications including those for residential, commercial and healthcare. Aaron has worked on projects with various groups & associations including the definitive study on UV inactivation of airborne bioterrorism agents sponsored by RTI, the United States EPA & US National Homeland Security. Aaron is frequent guest speaker and lecturer and contributes to publications on IAQ technologies and UV disinfection. Aaron is a member on various ASHRAE committees including TC2.9 Ultraviolet Air and Surface Treatment and the Programs Chair for TC2.9.  www.freshaireuv.com



References:
2) Disinfection and Sterilization Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)
3) US National Library of Medicine National Institutes of Health: The History of Ultraviolet Germicidal Irradiation for Air Disinfection  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2789813/
4) Far-UVC light: A new tool to control the spread of airborne-mediated microbial diseases

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