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Edward Nardell, MD, is a professor of medicine (global health) at Harvard Medical School and a professor of public health (Environmental Health; Immunology and Infectious Diseases) at the Harvard T.H. Chan School of Public Health, both in Boston, Massachusetts.

Rethinking the application of air disinfection in the era of COVID-19.


Fans, Filters, Rays, or Ions?

's) Editorial Board members—a diverse group of professionals dedicated to advancing infection prevention and control practices. This series highlights each member's unique expertise and contributions to the field.

From groundbreaking research to innovative strategies, these experts are at the forefront of enhancing health care safety. Join us as we learn their insights, experiences, and visions for the future, providing valuable knowledge and inspiration to elevate infection control protocols.

In this installment, we hear from Tabrikah Mohammed, MSc, BSN, CIC, CPHQ, FAPIC, senior infection control officer, MSc, BSN, TQM, CIC, CPHQ, FAPIC. 

Tabrikah Mohammed, MSc, BSN, CIC, CPHQ, FAPIC, is an accomplished nursing professional with a diverse educational background and vast experience in infection control. She obtained a bachelor of nursing degree from Sharjah University in 2011 and a master of health care administration from the Royal College of Surgeon Ireland in 2013.

Tabrikah has furthered her expertise by obtaining certification as a CIC in 2018 and a CPHQ in 2021. She is also the founder of the IPQ Academy, where she imparts her knowledge and experience to other health care professionals. As the cofounder, head of the scientific committee, and infection control expert at the 

Middle East North Africa Federation for Hospital Sterilization Sciences

 (MENA FHSS), she has significantly contributed to the healthcare sector.

Emirates Infection Prevention and Sterilization Society

 (EIPSS), a nonprofit organization dedicated to advancing knowledge in infection prevention and sterilization practices in the United Arab Emirates. EIPSS operates under the 

Currently, Tabrikah serves as a senior infection control officer in 

, where she applies her skills and knowledge to ensure the safety of patients and healthcare workers. She is also a member of the 2023 editorial advisory board for 

, a testament to her reputation as an expert in infection control.

Tabrikah's contributions to infection control have been recognized through several awards, including the 

IP Idol from Certification Board of Infection Control and Epidemiology, Inc

 by Saudi Society for Infection Prevention and Control in 2023. She is also an international speaker at various conferences and conducts workshops.

Tabrikah sees these topics as trending right now:

These programs aim to optimize the use of antibiotics to combat antibiotic resistance. They involve the proper selection, dosage, and duration of antibiotic treatment to minimize resistance and adverse effects.

: Real-time data and advanced analytics track infection trends and outbreaks within healthcare facilities, allowing quicker and more effective responses.

Artificial intelligence and machine learning

: These technologies are applied to predict outbreaks and optimize infection control strategies.

Personal Protective Equipment (PPE) Innovation

: PPE is continually being innovated, with improvements in comfort, durability, and protection levels. Reusable PPE is also being developed to address supply chain issues and sustainability concerns.

Infection Control in Nonhospital Settings

: Infection prevention in long-term care facilities has become a major focus, particularly due to residents' vulnerability to infections like COVID-19 and influenza.

: There’s increased attention to infection prevention in schools, workplaces, and other community settings.

: Online platforms for infection prevention training have expanded, making education more accessible and scalable.

: There’s a growing emphasis on interprofessional education and collaboration in infection prevention, recognizing that effective infection control requires teamwork across various healthcare disciplines.

: Educating patients and their families on infection prevention practices, such as hand hygiene and recognizing signs of infection, is becoming more prevalent.

: There is a trend towards involving patients in their care, including infection prevention measures, to improve outcomes.

: There is an increasing focus on sustainable practices in infection prevention, such as reducing single-use plastics and developing environmentally friendly disinfectants.

Infection Prevention in Nonhospital Settings:

There is a growing focus on infection prevention in long-term care facilities, outpatient clinics, and community settings. Tailored infection control measures are being developed for these environments.

Telehealth services have expanded significantly, reducing the need for in-person visits and thereby lowering the risk of infection transmission. Remote monitoring of patients helps in managing infections and chronic conditions more effectively.

could focus on a range of timely and impactful topics. Here are her suggestions:

1. Emerging Infectious Diseases and Global Threats

 Coverage of the latest research and developments regarding new viruses or bacteria, particularly those with pandemic potential.

 Updates on global efforts to prevent and control infectious diseases, including responses to outbreaks and lessons learned from recent events.

 New technologies, treatments, and policies to mitigate the rise of drug-resistant infections.

 Strategies for improving AMR monitoring in healthcare settings.

3. Infection Control in Special Populations

 Best practices for preventing infections in nursing homes and other long-term care settings.

 Specialized approaches to infection control in pediatric units.

4. Health Care-Associated Infections (HAIs)

 Latest strategies, protocols, and technologies for preventing HAIs, with a focus on surgical site infections, catheter-associated infections, and ventilator-associated pneumonia.

 Case studies and lessons learned from recent HAI outbreaks.

5. Environmental Hygiene and Disinfection

 New products, technologies, and practices in environmental cleaning and disinfection.

Role of air quality in infection control:

 Research on the impact of ventilation and air purification in preventing the spread of infections.

 Strategies for healthcare professionals to address vaccine hesitancy and counter misinformation.

 Updates on new vaccines and vaccine delivery methods.

7. Technology and Digital Health in Infection Control

AI and machine learning in infection prevention:

 How artificial intelligence predicts and prevents outbreaks in healthcare settings.

 The role of telehealth in infection control, especially in managing patients with infectious diseases remotely.

 How the pandemic has changed infection control practices permanently.

 Future-proofing infection control protocols.

9. Infection Control in Nonhospital Settings

Infection prevention in outpatient clinics:

 Best practices for clinics, dental offices, and other non-hospital healthcare settings.

 Strategies for preventing infections in schools and workplaces, especially with the increasing focus on respiratory illnesses.

Continuing education for healthcare workers:

 New programs, tools, and certifications in infection prevention.

 How to involve patients and their families in infection prevention efforts.

Meet the experts shaping infection prevention: Infection Control Today's Editorial Board members share insights, experiences, and cutting-edge strategies to enhance health care safety and quality. Meet Tabrikah Mohammed, MSc, BSN, CIC, CPHQ, FAPIC.

Meet Infection Control Today's Editorial Board Member: Tabrikah Mohammed, MSc, BSN, CIC, CPHQ, FAPIC

This month’s CDC HICPAC (Healthcare Infection Control Practices Advisory Committee) meeting focused on answering questions posed by CMS. The answers will serve as a guide for revising recommendations regarding controlling the spread of airborne pathogens.

One of the questions dealt with the definition of “severe illness,” which has been a prevention goal of COVID-19 interventions. “Severe Illness” was redefined as not just the prevention of “hospitalizations and deaths” but the prevention of “morbidity and mortality and other adverse outcomes.”This would include the disabling effects of long COVID and was a welcome change.

The question regarding whether source control (masking) should always be used in facilities had only one supporting vote. This was surprising because health care facilities are where sick patients congregate. Facilities will, thus, have higher rates of spread than found in communities. Not having a policy of universal masking poses a definite risk to immunocompromised patients and a 

. In many indoor settings, including infusion centers, which are crowded with patients and visitors, universal masking does not occur. 

Despite the persistence of SARS-CoV-2 and a looming H5N1 epidemic, most of the Committee, except for one member, appeared to want to maintain a status quo in our approach to airborne illnesses. The committee consensus was that N95 masks had not been conclusively shown to be more effective than masks or surgical masks in all clinical settings.
 
Source control was also discussed. However, the option that appeared to have HICPAC support was to only recommend the use of N95 masks some of the time, depending upon the pathogen; otherwise, surgical masks were advised. This made little sense since surgical masks do not adequately protect against pathogens that can spread through the air. By the time you can evaluate a patient to determine what type of pathogen the patient has, it may be too late to block transmission to the health care worker.

Even if the patient just has a cold, why should the worker be exposed to an illness that would necessitate several days off of work, or if paid sick leave was not available, going to work and 

placing immunocompromised patients at risk

? I would have recommended universal N95 masks, as outlined below in strategy “Narrative B.” 

Even a clear statement that health care workers can voluntarily wear their own N95 masks failed with a 6 to 5 vote. The committee opted to follow another Federal Agency's policy that places voluntary use at the employer's discretion. If a worker was immunocompromised or had an at-risk relative at home, one might only be willing to work in health care if allowed to wear an N95 mask. In health care, unlike many other work settings, a worker never knows when one will be exposed to a dangerous airborne occupational hazard. For some, the committee’s decision appeared to be about whether a facility’s administration or a front-line nurse will decide if the treating health care provider can wear an N95 mask. Ironically, in 

 its mask guidance to allow the public to choose to wear an N95 mask.
 
Surgical masks are intended to protect the patient from droplets and spit produced by a surgeon. They have some effectiveness regarding source control but will not provide the wearer with adequate protection. Some committee members justified their decision by stating N95 masks were too burdensome to be uniformly used and that health care facilities must also focus on other major problems they face, such as health care staffing shortages and 

However, COVID-19 and long COVID are a major cause of workforce shortages. In the United Kingdom, recent research has found a 

third of health care workers have symptoms of long COVID

. In addition, the psychological stresses of the pandemic, along with viral damage of 

well be a significant driver of the violence

 we are seeing in schools, hospitals, traffic accidents, and our society as a whole.
 
The health care workforce can be exposed to sizeable biological dosages of airborne pathogens for extended periods. In this setting, research trials on masking may not always detect differences between surgical and N95 masks since exposure dosages may be far too high. Any break in the protocol of wearing an N95 mask can result in an infection. In addition, 

a worker can be infected through their eyes

.

N95 masks are currently widely available, but availability may drop as manufacturers cut back or curtail protection due to decreased demand. This may leave us exposed when we are hit with our next pandemic. H5N1 is a looming threat that we need to be prepared for. Thus, one could argue that a facility should maintain a 6-month supply of respirators at pandemic usage levels and draw from this supply for staff personal protective equipment (PPE) usage.
 
One must ask, will workers have adequate protection? The answer is that masks alone do not afford optimal protection in health care settings; a layered approach is needed emphasizing optimal-safe ventilation. More facilities 

. Remember, dosage and exposure time determine your chances of infection.

Our current approach to reducing the spread of airborne pathogens must focus on reducing viral dosage. Strong evidence supports that N95 masks will reduce dosage exposure far better than surgical masks. However, this reduction may not prevent infection in all clinical settings. Instead of NOT recommending N95 masks, we must add additional layers to reduce exposure dosage. These layers include maximizing ventilation, testing, and source control. All are needed to maintain patient safety and a healthy health care workforce. 

The CDC HICPAC discussed updates to airborne pathogen guidelines, emphasizing the need for masks in health care. Despite risks, the committee resisted universal masking, highlighting other mitigation strategies


CDC HICPAC Considers New Airborne Pathogen Guidelines Amid Growing Concerns

Jenny Hayes, MSN, RN, CIC, CAIP, CASSPT, the director of infection prevention at Jefferson Health East Region in New Jersey

From groundbreaking research to innovative strategies, these experts are at the forefront of enhancing health care safety. Join us as we learn their insights, experiences, and visions for the future, providing valuable knowledge and inspiration to elevate infection control protocols. Meet Jenny Hayes, MSN, RN, CIC, CAIP, CASSPT, the director of infection prevention for Jefferson Health—East Region, in Stratford, New Jersey.

MSN, RN, CIC, CAIP, CASSPT, the director of infection prevention at Jefferson Health East Region in New Jersey, has built an impressive career dedicated to infection control. Her journey began early in nursing when she noticed critical gaps in basic hygiene practices. Starting as an LPN and eventually advancing to a master's degree, Hayes observed firsthand the severe consequences of infection in different healthcare settings, including dialysis and critical care, where patients faced high risks of bloodstream infections. Her experiences shaped her commitment to infection prevention and led her to specialize in this field.

“I always knew that I think I would like to be the infection control nurse because they would come to our orientations at hospitals, or come and, do you know, certain educational seminars, and I always highly valued everything they had to say, and thought that's what I would like to do someday,” Hayes said.

In 2005, Hayes officially entered the infection prevention field, working in large academic health care facilities and outpatient settings. Her roles have included overseeing infection control protocols across more than 200 facilities and collaborating on facility design and construction projects to ensure proper infection prevention measures, such as hand hygiene accessibility and airflow in surgery centers.

Today, at Jefferson Health, Hayes monitors emerging infectious threats like Candida auris, a highly resistant fungus increasingly common in health care. She emphasizes the importance of vigilant surveillance and isolation protocols, particularly for patients from high-risk environments like long-term care facilities. Another focus is the growing threat of antibiotic resistance, both in health care and agriculture, which she warns could lead to a return to pre-antibiotic days if unchecked.

Hayes also sees potential in artificial intelligence (AI) for infection prevention. She hopes AI can streamline infection surveillance, allowing infection preventionists to focus more on hands-on prevention measures. As infection control continues to evolve, Hayes calls for greater emphasis on antibiotic stewardship and AI's role in infection prevention.

“How's [AI] going to play out for the role of the infection preventionist?” Hayes said, “Hopefully, it's going to allow the opportunity to get the infection preventionist closer to the bedside, closer to the procedural areas, really being able to engage in the hand hygiene observations, [personal protective equipment] usage, all the things that we preach about, and maybe perhaps you do some audits on, but it's difficult to be there in the moment. So, it may change the role of how you carry out your infection preventionist activities.”

Meet the experts shaping infection prevention: Infection Control Today's Editorial Board members share insights, experiences, and cutting-edge strategies to enhance health care safety and quality. Meet Jenny Hayes, MSN, RN, CIC, CAIP, CASSPT. 


Meet Infection Control Today's Editorial Advisory Board Member: Jenny Hayes, MSN, RN, CIC, CAIP, CASSPT

Because instrument sterilization is a key operational need for every health care facility--regardless of size--offering surgical or other invasive procedures, the location of that sterilization process is completed is important for an infection preventionist and an operations manager to be involved in sterilization operations. The process, the operations manager, the infection preventionist, and, most importantly, the patient will benefit from the collaboration of infection preventionists and operations managers and their learning about the benefits of integrating operating models.

Several different operating models are available for operating models, including 1 hospital site central processing department (CPD) and 1 ambulatory facility CPD. Jenny Hayes, MSN, RN, CIC, CAIP, CASSPT, and the infection preventionists RN, Clinical IV at the Hospital of the University of Pennsylvania in Philadelphia, Pennsylvania, spoke about this topic in her presentation at the 

Association for Professionals in Infection Control and Epidemiology (APIC) 2022 Annual Conference

, held June 13-15, 2022, in Indianapolis, Indiana. Hayes’ presentation titled, “Moving Sterilization Off-Site,” discussed the challenges and role of infection prevention in both design and operations sterilization operations.

) at the conference and stated what she hoped both APIC attendees and 

 readers learn from her presentation. “The integrated operations models serve as an interface to a single entity model in a horizontally-integrated health care system. Infection preventions serves in policy development and compliance to include the additional measures of instrument handling and transport offsite.”

Hayes does caution, though, that off-site sterilization cannot be the sole sterilization for any sized facility. “This does not eliminate on-site sterilization as that will always be need in case of inclement weather, delays, and emergencies. High level disinfection of endoscopes should also remain onsite due to the required 1- to 2-hour timeframe from scope-use to full decontamination of the endoscope.”

The infection preventionist’s role extends far beyond simply surveillance activities and into  an integrated member of design and operations.


IPs Should Serve in Off-Site Sterilization Policy Development/Compliance 

Realism is what 3-D glasses aim to give theatergoers through polarized lenses, digital projectors, and IMAX 3-D camera systems for an immersive experience that imitates real life.

A 3-D approach to environmental cleaning aims to give Infection prevention and control (IPC) and environmental services (EVS) a realistic view of indoor spaces that includes not only surfaces (2-D) but the air above surfaces (3-D) because a) we often deal with immune-compromised persons; b) infectious exposure can occur through both airborne and surface routes, and c) infectious exposure is most often a 3-dimensional and immersive rather than a 2-dimensional process.
Respiratory infections are a major part of health care-associated infections (HAIs), as between 23 to 63% of all HAIs are respiratory infections.

“If the pathogen has some part of its life cycle in the respiratory tract, it is more likely to be present in aerosols generated and projected into the surrounding air by breathing, talking, coughing, sneezing and singing,” notes researchers in the 2006 report, “Factors involved in the aerosol transmission of infection and control of ventilation in health care premises.”

In 2024, the World Health Organization suggested the umbrella term infectious respiratory particles (IRPs) to simplify and include aerosols (tiny particles), droplets (larger particles), and other airborne infectious particles in a single metric.

While our ability to assess the quality of 2-D surface cleaning using simple, science-based tools is fairly well understood (see Sidebar, “Seeing in 2-D”), seeing airborne matter such as IRPs is not; hence, this article focuses on the third dimension of cleaning—air monitoring and purification.

As the medical model teaches us, diagnosis precedes treatment, so diagnosing indoor air should precede treating or purifying it, and this involves understanding how IRPs behave indoors.

One way to visualize the movement of IRPs indoors is to use 3-D modeling. 3-D modeling can help simulate the behavior of particles in different scenarios, such as inpatient rooms, waiting areas, restrooms, or hallways. By using 3-D modeling, we see how factors such as the distance, duration, and direction of exposure; the size, shape, and density of the particles; the airflow, temperature, and humidity in the space; and ventilation and filtration of the indoor air, can potentially affect the risk of infection.

Generally, smaller and lighter particles stay suspended in the air for more extended periods than larger and heavier ones, which tend to settle on surfaces more quickly. Some studies estimate that the average time for bacteria and viruses to stay airborne is about 1 to 2 hours, though this varies widely depending on conditions and types of microbes. For example, some research has shown that the coronavirus that causes COVID-19 can remain viable as an IRP for up to 3 hours, while other studies suggest that it can persist for less than an hour. (See sidebar, “IRP Dynamics”)

In addition to 3-D modeling, active air monitoring technology enables “seeing” invisible airborne particles down to .1 micron (eg, the COVID-19 virus is ~.1 micron in size)—plus detecting Total VOCs (TVOC), carbon dioxide (CO

), temperature, and humidity—and when coordinated with real-time air purification, enables a 3-D approach to facility cleaning.

The best strategy for combining indoor air quality (IAQ) monitoring and purification in health care facilities depends on the type, level, and source of the indoor environmental contaminants, as well as the specific needs and characteristics of the people in the facility. However, some general principles and guidelines are:

Continuous air monitoring is key to identifying and quantifying indoor air pollutants, helping assess health effects, and evaluating the effectiveness of air purification measures in real time. For example, units may have internal fans that actively sample the air and upload the data wirelessly to a building management system or cloud-based software every several seconds.

Continuous monitoring is important as it shows trends such as particle levels during vacuuming or cleaning processes, VOC levels during medical procedures, disinfection or other activities, and or CO2 levels, which serve as a proxy for other pollutants.

Air monitors should be accredited by an independent source such as RESET (Regenerative Ecological, Social, and Economic Targets), which specifies requirements to help ensure the quality, timeliness, and accuracy of data—such as levels of fine particles 2.5 microns (PM 2.5) and smaller, TVOCs, CO2, Temperature, and Humidity—and enables periodic calibration and audits of monitor performance. RESET is recognized by the International WELL Building Institute (IWBI) and the LEED IAQ innovation credit.

Air monitors with customizable sensors enable flexibility in detecting particular airborne contaminants and should offer data security features to control access to sensitive information.

Air purification can be achieved by various means, such as ventilation, filtration, UV-C, adsorption, and more. The choice and combination of the air purification methods should be based on the specific characteristics of the indoor air pollutants, such as their size, concentration, chemical composition, and biological activity, as well as the availability, cost, efficiency, and safety of the methods. For example, EPA states that “in order for an air cleaner to be effective in removing viruses from the air, it must be able to remove small airborne particles (in the size range of 0.1-1 um).”

Air purifiers in healthcare spaces should incorporate technologies associated with log reduction, such as a 4-log (99.99%) to 6-log (99.9999%) microbial log reduction.

Air monitoring and purification should be integrated and coordinated with surface cleaning protocols as part of a comprehensive, holistic, 3-D approach to indoor environmental quality management in health care facilities.

ASHRAE Compliance, IAQP, Lower Costs—Have Your Cake and Eat It Too

ASHRAE 62.1’s Indoor Air Quality Procedure (IAQP) approves the use of peripheral air purifiers to meet its clean air equivalency requirements as an alternative to mandatory HVAC ventilation rates, such as 5 air changes per hour. This reduces the load placed on HVAC systems and the need to use costly high-MERV filters at the HVAC level, lowering resistance to airflow, fan/motor wear, energy, and overall costs.

, released in 2023, further validates the approach as it “establishes minimum requirements aimed at reducing the risk of disease transmission through exposure to infectious aerosols” and provides 

requirements for use of filtration and air cleaning … [eg, HEPA filters, UV, etc] for equivalent clean airflow rate target per occupant of pathogen-free airflow, reducing the risk of infection.”

To effectively use ASHRAE’s IAQP in health care, facility managers should integrate it with the sometimes more stringent air-change recommendations from ASHE, facility operations, and health care-focused groups. This involves:


•Conducting thorough risk assessments to identify and control potential sources of contamination.

•Ensuring that air quality targets align with health care-specific requirements, particularly in critical areas such as operating rooms and isolation units.

•Implementing robust monitoring and maintenance programs to verify that air quality remains within acceptable limits.

In-room or peripheral units equipped with MERV 19 or ULPA filtration and other technologies, such as UV-C, can do the heavy lifting regarding particle removal closer to the source and effectively reduce airborne pathogens.

WHO has recently updated its list of dangerous pathogens that could cause the next pandemic—consulting with some 200 scientists about 1,652 pathogenic species—finding the number has jumped to 30 vs about a dozen in 2017-2018—and many of these are airborne.


While we do not have 3-D glasses to assess our work in cleaning on and above surfaces, a 3-D approach to hygiene using surface and air monitoring and purification systems provides a solid path to realism in the health care theatre.

Al-Tawfiq JA, Pearlman A. HAI perspectives. 

Rong R, Lin L, Yang Y, et al. Trending prevalence of healthcare-associated infections in a tertiary hospital in China during the COVID-19 pandemic. 

 2023;23(1):41. doi:10.1186/s12879-022-07952-9

A 3-D approach to infection control involves air and surface cleaning, leveraging monitoring, purification, and modeling technologies to reduce respiratory infection risks in health care environments.

Edward Nardell, MD

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