Role of mechanical ventilation in the airborne transmission of infectious agents in buildings

Infectious disease outbreaks and epidemics such as those due to SARS, influenza, measles, tuberculosis, and Middle East respiratory syndrome coronavirus have raised concern about the airborne transmission of pathogens in indoor environments. Significant gaps in knowledge still exist regarding the role of mechanical ventilation in airborne pathogen transmission. This review, prepared by a multidisciplinary group of researchers, focuses on summarizing the strengths and limitations of epidemiologic studies that specifically addressed the association of at least one heating, ventilating and/or air‐conditioning (HVAC) system‐related parameter with airborne disease transmission in buildings. The purpose of this literature review was to assess the quality and quantity of available data and to identify research needs. This review suggests that there is a need for well‐designed observational and intervention studies in buildings with better HVAC system characterization and measurements of both airborne exposures and disease outcomes. Studies should also be designed so that they may be used in future quantitative meta‐analyses.     

Role of air distribution in SARS transmission during the largest nosocomial outbreak in Hong Kong

Severe acute respiratory syndrome (SARS) is primarily transmitted by bio-aerosol droplets or direct personal contacts. This paper presents a detailed study of environmental evidence of possible airborne transmission in a hospital ward during the largest nosocomial SARS outbreak in Hong Kong in March 2003. Retrospective on-site inspections and measurements of the ventilation design and air distribution system were carried out on July 17, 2003. Limited on-site measurements of bio-aerosol dispersion were also carried out on July 22. Computational fluid dynamics simulations were performed to analyze the bio-aerosol dispersion in the hospital ward. We attempted to predict the air distribution during the time of measurement in July 2003 and the time of exposure in March 2003. The predicted bio-aerosol concentration distribution in the ward seemed to agree fairly well with the spatial infection pattern of SARS cases. Possible improvement to air distribution in the hospital ward was also considered. PRACTICAL IMPLICATIONS: Our study revealed the need for the development of improved ventilation and air-conditioning systems in an isolation ward or a general hospital ward for infectious respiratory diseases. The outbreak in Ward 8A, which was in a general hospital and could house nearly 40 patients, demonstrated the cross-infection risks of respiratory infectious diseases in hospitals if a potential highly infectious patient was not identified and isolated. Our example simulation, which extended the SARS Busters' design for an isolation room to Ward 8A, demonstrated that there was room for improvement to minimize cross-infection in large general hospital wards.     

The predictions of infection risk of indoor airborne transmission of diseases in high-rise hospitals: Tracer gas simulation

The spread of diseases from infected patients within hospitals is resulting in many human casualties. If a virus were to be transmitted through uncontrolled air movement within a hospital and were then to infect other patients or healthy visitors, it would be impossible to contain the spread of the disease. The purpose of this paper is to apply reliable boundary conditions based on previous studies in order to analyze the airflow pattern caused by the stack effect in high-rise hospitals. An analysis was carried out on the vertical airborne transmission of viruses according to the location of the infected patients. The horizontal airborne transmission based on the characteristics of the supply air diffuser and return air grille was also analyzed by using the multi-zone airflow simulation and tracer gas (CFD) simulation. In addition, this paper explored solutions to prevent the spread of airborne pathogenic bacteria by analyzing various alternatives of HVAC systems and basic data on ventilation system planning for high-rise hospitals.     

Estimating the germicidal effect of upper-room UVGI system on exhaled air of patients based on ventilation efficiency

Upper room (UR)-ultraviolet germicidal (UVGI) systems, one of several disinfection applications of UV, target airborne infectious diseases in rooms of buildings such as healthcare facilities. Previous studies have introduced many experiments showing the germicidal effect of UR-UVGI systems. In this study, a novel numerical method of estimating the germicidal effect of UR-UVGI systems for air exhaled by ward patients was introduced. The method adopts and modifies the concept of ventilation efficiency because the germicidal effect depends upon how the air containing airborne infectious particles flows and stays within UV-radiated area. A case study based on a four-patient ward showed that UV doses were correlated with the age of the air exhaled by a source patient, as expected. Moreover, the UV doses were considerably affected by the position of the UR-UVGI system. Inactivation rates of the influenza virus estimated using the UV doses, were in the range of 48–74%, and those of Mycobacterium tuberculosis were 68–90% in the breathing area of a neighboring patient. The results indicate not directly the decreased concentration of airborne infectious particles, but the possibility of inactivation caused by the UR-UVGI system, which is useful for system optimization.     

Multi-zone modeling of probable SARS virus transmission by airflow between flats in Block E, Amoy Gardens

More than 300 residents of a private high-rise housing estate were infected with severe acute respiratory syndrome within a short period during the 2003 epidemic in Hong Kong. The outbreak occurred after the identified index patient visited a flat on a middle floor in Block E of the Amoy Gardens estate on two nights. Approximately 45% of the subsequently infected people resided in Block E, while the other 55% of infected cases mainly resided in six other blocks close to Block E. The distribution of the infected flats in Block E conformed to a non-uniform spatial pattern. Probable environmental causes for airborne transmission associated with the air movements between flats in Block E are identified. The well-established multi-zone airflow modeling method was used to analyze the virus-laden bio-aerosol dispersion between flats through door and window leakage areas in Block E under six different scenarios. The distribution of infection risk in Block E matched with the virus concentrations in flats predicted with the use of multi-zone modeling. Our study shows the importance of ventilation design in high-rise residential apartments. PRACTICAL IMPLICATIONS: The present study on the Amoy Gardens outbreak presented a scenario in which crowded living spaces might lead to infection disasters. There is a need to improve the current sanitary drainage design and maintenance standards to avoid any leakage of foul gas into the indoor environments. Our study revealed the need for a review of indoor air quality and ventilation design in buildings including offices, homes and hotels. The study has implications to public health in, for example, the control of other airborne respiratory infectious diseases such as influenza, and in bio-terror safety in buildings.     

Investigating a safe ventilation rate for the prevention of indoor SARS transmission: An attempt based on a simulation approach

This paper identifies the “safe ventilation rate” for eliminating airborne viral infection and preventing cross-infection of severe acute respiratory syndrome (SARS) in a hospital-based setting. We used simulation approaches to reproduce three actual cases where groups of hospital occupants reported to be either infected or not infected when SARS patients were hospitalized in nearby rooms. Simulations using both computational fluid dynamics (CFD) and multi-zone models were carried out to understand the dilution level of SARS virus-laden aerosols during these scenarios. We also conducted a series of measurements to validate the simulations. The ventilation rates (dilution level) for infection and non-infection were determined based on these scenarios. The safe ventilation rate for eliminating airborne viral infection is to dilute the air emitted from a SARS patient by 10000 times with clean air. Dilution at lower volumes, specifically 1000 times, is insufficient for protecting non-infected people from SARS exposure and the risk of infection is very high. This study provides a methodology for investigating the necessary ventilation rate from an engineering viewpoint.     

Predictions and measurements of the stack effect on indoor airborne virus transmission in a high-rise hospital building

As the viral diseases such as Severe Acute Respiratory Syndrome (SARS) and Influenza A (H1N1) occur in many countries recently, the epidemic of those influenza viruses causes many human casualties. Moreover, the second infection from infected patients particularly within general hospitals frequently takes places due to improperly hospitalized and/or quarantined patients. Accordingly, it becomes a great concern to accommodate safer ventilation system in general hospital wards against such airborne transmitted viruses. It is also a recent trend that many urban general hospitals are designed and constructed as high-rises. If a virus is transmitted through uncontrolled air movement within a hospital and then infected other patients or healthy visitors, it might be impossible to control the spread of the disease. Thus research has been preceded scrutinizing stack effect on the indoor airborne virus transmission in large hospitals by conducting both the field measurement and numerical analysis according to the outdoor temperature and the releasing vertical points of the tracer gas assumed as a viral contaminant. In the field measurement of a high-rise hospital, the indoor airflow was affected by the stack effect of vertical chute of the building. The numerical simulation was verified by comparing its prediction results and the field measurement data. In result, very high possibility has witnessed that the airborne contaminant emitted from the infected patients in the lower floors could be transported to the higher floors through the airflow driven by the stack effect.     

Spatial distribution of infection risk of SARS transmission in a hospital ward

The classical Wells–Riley model for predicting risk of airborne transmission of diseases assumes a uniform spatial distribution of the infected cases in an enclosed space. A new mathematical model is developed here for predicting the spatial distribution of infection risk of airborne transmitted diseases by integrating the Wells–Riley equation into computational fluid dynamics. We applied our new integrated model to analyze a large nosocomial SARS outbreak in Hong Kong during the 2003 SARS epidemics, which was studied in the literature with regard to the association between airflow and SARS infection.     

Ventilation, temperature, and HVAC characteristics in small and medium commercial buildings in California

This field study of 37 small and medium commercial buildings throughout California obtained information on ventilation rate, temperature, and heating, ventilating, and air-conditioning (HVAC) system characteristics. The study included seven retail establishments; five restaurants; eight offices; two each of gas stations, hair salons, healthcare facilities, grocery stores, dental offices, and fitness centers; and five other buildings. Fourteen (38%) of the buildings either could not or did not provide outdoor air through the HVAC system. The air exchange rate averaged 1.6 (s.d. = 1.7) exchanges per hour and was similar between buildings with and without outdoor air supplied through the HVAC system, indicating that some buildings have significant leakage or ventilation through open windows and doors. Not all buildings had sufficient air exchange to meet ASHRAE 62.1 Standards, including buildings used for fitness centers, hair salons, offices, and retail establishments. The majority of the time, buildings were within the ASHRAE temperature comfort range. Offices were frequently overcooled in the summer. All of the buildings had filters, but over half the buildings had a filter with a minimum efficiency reporting value rating of 4 or lower, which are not very effective for removing fine particles. PRACTICAL IMPLICATIONS: Most U.S. commercial buildings (96%) are small- to medium-sized, using nearly 18% of the country's energy, and sheltering a large population daily. Little is known about the ventilation systems in these buildings. This study found a wide variety of ventilation conditions, with many buildings failing to meet relevant ventilation standards. Regulators may want to consider implementing more complete building inspections at commissioning and point of sale.     

Ventilation rates and health: multidisciplinary review of the scientific literature

The scientific literature through 2005 on the effects of ventilation rates on health in indoor environments has been reviewed by a multidisciplinary group. The group judged 27 papers published in peer-reviewed scientific journals as providing sufficient information on both ventilation rates and health effects to inform the relationship. Consistency was found across multiple investigations and different epidemiologic designs for different populations. Multiple health endpoints show similar relationships with ventilation rate. There is biological plausibility for an association of health outcomes with ventilation rates, although the literature does not provide clear evidence on particular agent(s) for the effects. Higher ventilation rates in offices, up to about 25 l/s per person, are associated with reduced prevalence of sick building syndrome (SBS) symptoms. The limited available data suggest that inflammation, respiratory infections, asthma symptoms and short-term sick leave increase with lower ventilation rates. Home ventilation rates above 0.5 air changes per hour (h(-1)) have been associated with a reduced risk of allergic manifestations among children in a Nordic climate. The need remains for more studies of the relationship between ventilation rates and health, especially in diverse climates, in locations with polluted outdoor air and in buildings other than offices. PRACTICAL IMPLICATIONS: Ventilation with outdoor air plays an important role influencing human exposures to indoor pollutants. This review and assessment indicates that increasing ventilation rates above currently adopted standards and guidelines should result in reduced prevalence of negative health outcomes. Building operators and designers should avoid low ventilation rates unless alternative effective measures, such as source control or air cleaning, are employed to limit indoor pollutant levels.     

通风与空气过滤对控制室内生物污染的影响研究

在分析室内空气微生物的来源、存活及传播等规律的基础上,介绍了通风与空气过滤两种建筑室内生物污染工程控制方法,采用微积分方法建立了通风过滤模型,分析了通风对降低室内生物污染浓度的影响,给出了通风空调系统各空气过滤器滤菌效率的设计计算公式。理论计算结果表明当以控制室内生物污染为主要目的时,自然通风效果不佳,应考虑机械通风;提高集中空调系统的各级过滤器滤菌效率,有助于改善室内生物污染状况。     

An energy impact assessment of ventilation for indoor airborne bacteria exposure risk in air-conditioned offices

Treatment of fresh air in ventilation systems for air-conditioned offices consumes a significant amount of energy and affects the indoor air quality (IAQ). In this study, energy impact on the ventilation systems was examined against certain IAQ objectives for indoor airborne bacteria exposure risk in air-conditioned offices of Hong Kong. The relationship between thermal energy consumptions and indoor airborne bacteria exposure levels based on regional surveys was investigated. The thermal energy consumptions of ventilation systems operating for carbon dioxide (CO₂) exposure concentrations between 800 and 1200 ppmv for typical office buildings and the corresponding failure probability against some target bacteria exposure levels were evaluated. The results showed that, for a reference indoor environment at a CO₂ exposure concentration of 1000 ppmv, the predicted average thermal energy saving of ventilation system for a unit increment of the expected risk of unsatisfactory IAQ of 1% was 55 MJ m⁻² yr⁻¹ and for a unit decrement of 1%, the predicted additional thermal energy consumption was 58 MJ m⁻² yr⁻¹ respectively. This study would be a useful source of reference in evaluation of the energy performance of ventilation strategies in air-conditioned offices at a quantified exposure risk of airborne bacteria.     

气载致病微生物和空气消毒技术

近年来全球频繁暴发通过空气传播的传染疾病,造成疫情的大范围传播,给人类健康带来严重威胁。空气中的病毒和细菌属于气载微生物,可以在空气中存活并进行传播。这种传播方式相较于水、土壤等其他媒介的传播,具有传播速度快、影响范围广的特点,极易引起社会恐慌。介绍了气载致病微生物及其危害,阐明了气载致病微生物的存在形式和传播途径,归纳总结了国内外在空气微生物控制方面的相关标准,并系统介绍了各类空气消毒技术和净化设备的特点和应用情况。     

SARS诊疗室内的气流分布优化研究

本文分析了SARS病毒特性及其传播机理,结合相关标准并借鉴生物安全技术归纳出SARS诊疗室内的气流分布要求,给出了相关的评价指标。模拟和实验结果表明尽管都采用单侧顶送异侧下回的风口布局方式,但是未必所有的送风口均能形成理想的气流定向流动,满足SARS诊疗室的气流分布要求。通过对多种气流分布方式的比较和总结,本文提出了适合SARS诊疗室的最佳气流分布方式。     

A simple method for differentiating direct and indirect exposure to exhaled contaminants in mechanically ventilated rooms

Many airborne infectious diseases can be transmitted via exhaled contaminants transported in the air. Direct exposure occurs when the exhaled jet from the infected person directly enters the breathing zone of the target person. Indirect exposure occurs when the contaminants disperse in the room and are inhaled by the target person. This paper presents a simple method for differentiating the direct and indirect exposure to exhaled contaminants in mechanically ventilated rooms. Experimental data for 191 cases were collected from the literature. After analyzing the data, a simple method was developed to differentiate direct and indirect exposure in mixing and displacement ventilated rooms. The proposed method correctly differentiated direct and indirect exposure for 120 out of the 133 mixing ventilation cases and 47 out of the 58 displacement ventilation cases. Therefore, the proposed method is suitable for use at the early design stage to quickly assess whether there will be direct exposure to exhaled contaminants in a mechanically ventilated room.     

Predictive models of control strategies involved in containing indoor airborne infections

Recently developed control measure modeling approaches for containing airborne infections, including engineering controls with respiratory protection and public health interventions, are readily amenable to an integrated-scale analysis. Here we show that such models can be derived from an integrated-scale analysis generated from three different types of functional relationship: Wells-Riley mathematical model, competing-risks model, and Von Foerster equation, both of the key epidemiological determinants involved and of the functional connections between them. We examine mathematically the impact of engineering control measures such as enhanced air exchange and air filtration rates with personal masking combined with public health interventions such as vaccination, isolation, and contact tracing in containing the spread of indoor airborne infections including influenza, chickenpox, measles, and severe acute respiratory syndrome (SARS). If enhanced engineering controls could reduce the basic reproductive number (R0) below 1.60 for chickenpox and 3 for measles, our simulations show that in such a prepared response with public health interventions would have a high probability of containing the indoor airborne infections. Combinations of engineering control measures and public health interventions could moderately contain influenza strains with an R0 as high as 4. Our analysis indicates that effective isolation of symptomatic patients with low-efficacy contact tracing is sufficient to control a SARS outbreak. We suggest that a valuable added dimension to public health inventions could be provided by systematically quantifying transmissibility and proportion of asymptomatic infection of indoor airborne infection. Practical Implications We have developed a flexible mathematical model that can help determine the best intervention strategies for containing indoor airborne infections. The approach presented here is scalable and can be extended to include additional control efficacies. If a newly emergent airborne infection should appear, the model could be quickly calibrated to data and intervention options at the early stage of the outbreak. Data could be provided from the field to estimate value of R0, the serial interval between cases, the distributions of the latent, incubation, and infectious periods, case fatality rates, and secondary spread within important mixing groups. The combination of enhanced engineering control measures and assigned effective public health interventions would have a high probability for containing airborne infection.     

Ventilation and health in non-industrial indoor environments: report from a European multidisciplinary scientific consensus meeting (EUROVEN)

Scientific literature on the effects of ventilation on health, comfort, and productivity in non-industrial indoor environments (offices, schools, homes, etc.) has been reviewed by a multidisciplinary group of European scientists, called EUROVEN, with expertise in medicine, epidemiology, toxicology, and engineering. The group reviewed 105 papers published in peer-reviewed scientific journals and judged 30 as conclusive, providing sufficient information on ventilation, health effects, data processing, and reporting, 14 as providing relevant background information on the issue, 43 as relevant but non-informative or inconclusive, and 18 as irrelevant for the issue discussed. Based on the data in papers judged conclusive, the group agreed that ventilation is strongly associated with comfort (perceived air quality) and health [Sick Building Syndrome (SBS) symptoms, inflammation, infections, asthma, allergy, short-term sick leave], and that an association between ventilation and productivity (performance of office work) is indicated. The group also concluded that increasing outdoor air supply rates in non-industrial environments improves perceived air quality; that outdoor air supply rates below 25 l/s per person increase the risk of SBS symptoms, increase short-term sick leave, and decrease productivity among occupants of office buildings; and that ventilation rates above 0.5 air changes per hour (h-1) in homes reduce infestation of house dust mites in Nordic countries. The group concluded additionally that the literature indicates that in buildings with air-conditioning systems there may be an increased risk of SBS symptoms compared with naturally or mechanically ventilated buildings, and that improper maintenance, design, and functioning of air-conditioning systems contributes to increased prevalence of SBS symptoms.     

生物颗粒在相邻房间运动的数值研究

采用数值计算方法对穿堂风条件下 ,外区房间中性质和SARS病毒类似的生物颗粒的运动情况及其对相邻的内区房间的影响进行分析。对不同的换气次数、不同的室内颗粒初始位置等工况进行了数值分析。结果表明 ,外区房间自然通风换气量的加大 ,可能会导致内区房间的生物颗粒数量增多 ;而颗粒初始位置距离内、外区相邻开口越近 ,运动到内区房间的颗粒数量也越多。     

The Helsinki Office Environment Study: Air Change in Mechanically Ventilated Buildings

Abstract The objective of this study was to assess the magnitude and balance of mechanical ventilation in the rooms of Helsinki metropolitan office buildings with different types of ventilation systems. A random sample of 50 office buildings was selected from the Building Registry. Of these buildings, the 33 that have a mechanical ventilation system were included in this study. Most office buildings in the Helsinki metropolitan area have a ducted supply and exhaust system and hot water radiator heating. Air recirculation is used in about half of the buildings which have a mechanical supply and exhaust system. The average exhaust airflow was 1.2 L/s, m² (SD 0.73) or 17.2 L/s per person (SD 11.6). The variation of the airflows was found to be very high among the buildings, and among the rooms within the buildings. Therefore, even though the ventilation rates on average comply with the Finnish building code, it was found that many people were working in offices with airflows which were either too low or unnecessarily high.     

Natural ventilation for reducing airborne infection in hospitals

High ventilation rate is shown to be effective for reducing cross-infection risk of airborne diseases in hospitals and isolation rooms. Natural ventilation can deliver much higher ventilation rate than mechanical ventilation in an energy-efficient manner. This paper reports a field measurement of naturally ventilated hospital wards in Hong Kong and presents a possibility of using natural ventilation for infection control in hospital wards. Our measurements showed that natural ventilation could achieve high ventilation rates especially when both the windows and the doors were open in a ward. The highest ventilation rate recorded in our study was 69.0 ACH. The airflow pattern and the airflow direction were found to be unstable in some measurements with large openings. Mechanical fans were installed in a ward window to create a negative pressure difference. Measurements showed that the negative pressure difference was negligible with large openings but the overall airflow was controlled in the expected direction. When all the openings were closed and the exhaust fans were turned on, a reasonable negative pressure was created although the air temperature was uncontrolled.