Let Airflow Show Pathogens the Door (or Window or Vent)

Momentum has been building for months for the World Health Organization (WHO) to acknowledge that SARS-CoV-2, the virus that causes COVID-19, is spread predominantly through the air. It’s an effort that might profoundly improve resources for infection prevention and, therefore, affect the way infection preventionists (IPs) do their jobs. Since July 2020, leading scientists have been pointing toward and signing open letters¹ supplying evidence² of the airborne transmission of the disease.^3,4 Recently updated WHO language reflects this evidence. As of April 30, 2021, the WHO updated its guidance advising that the virus can be spread in poorly ventilated and crowded settings…because aerosols remain suspended in the air.⁵

This means that all signs point to the inability to supply safe indoor air as the probable cause of a government shutdown and the transmission mode that some long-term care residents had little hope to avoid. Gone are the days when society accepts pathogens spread from public sewers (typhoid), diseased water (cholera), or poor ventilation (COVID-19). This is a watershed moment for the regulation of indoor air quality (IAQ).

Use Available Funding

In May 2020, the federal government began releasing payments from the Coronavirus Aid, Relief, and Economic Security Act Provider Relief Fund through the US Department of Health & Human Services (HHS). These funds came in the form of general and targeted distributions that expired June 30, 2021. Therefore, if a facility didn’t make investments with these funds, the hospital or long-term care facility stands to leave money on the table.

It is time to stop spending this money on medical consumables and apply it to a lasting solution. If these consumables are billed elsewhere in the facility’s provider fees, that could be construed as double-dipping.

This practice is not allowed and will result in unused funds. These valuable dollars should be used to make lasting improvements. How the organization allocates the money is important, and flexibility exists in sorting appropriate uses even now.

Timothy Crouch, a principal at the accounting company CliftonLarsonAllen (CLA), has been providing CLA accounting software to help health care providers identify appropriate uses. CLA recognized that many of its clients found it confusing to navigate how these funds can be used. The product they developed assists in tracking expenses and is continually updated by HHS.

The federal funds allocated for pandemic relief resulted in hundreds of thousands, and often millions, of dollars showing up in eligible health care provider accounts. Hospitals, nursing homes, and facilities in between began receiving direct deposits from the federal government. Executives and accountants have been trying to figure out what will be forgiven, what is a loan, and what will need to be returned. These funds provide a resource for moving forward on a solution. If alarm bells are ringing, it might not be too late to capitalize on this money for infection control. CLA is in discussion with IPs to place unused funds under contracts to be used for assessment services and infection control. The company can offer information on timelines and advise on provider relief funds.⁶

No Quick Fix

Air management is a broad issue involving many components. Don’t expect to discover a quick, all-in-one fix, and caution other decision makers against such solutions. A sound air management solution will require addressing many pollutants. People spend approximately 90% of their time in enclosed spaces, according to the International WELL Building Institute.⁷ Inhalation exposure to indoor air contaminants leads to a variety of health problems, such as headaches, asthma, cancer, ischemia, high blood pressure, heart disease, and infections caused by pathogenic viruses similar to SARS-CoV-2.⁸ Indoor pollutants are about 1000 times more likely to be transmitted to the lungs; thus, indoor air quality management is very important.⁹ Effective monitoring and proactive precautionary measures can prevent exposure.

The COVID-19 pandemic has spurred groundbreaking technological advances in products. For example, veriDART by SafeTraces leverages patented DNA-tagged tracer particles that safely mimic aerosol mobility and exposure to identify high-risk infection hot spots and transmission routes.¹⁰ The tracer can be released at a location mimicking a sick patient and the preceding pathway identified. This is a real-world, data-driven tool for assessment and remediation of infection pathways. In a recent project led by Kevin Grosskopf, PhD, a professor of architecture at the University of Nebraska–Lincoln, the Department of Energy used veriDART to assess and validate ventilation measures in residential care environments.¹¹

RHP Risk Management, which specializes in evaluating IAQ, building ventilation, and biological contaminants, currently employs the technology for clients and finds veriDART to be essential in providing validation for environmental controls, according to RHP Risk Management.¹²

When it comes to air management, manufacturers have embraced a quote attributed to management expert Peter Drucker: “If you can’t measure it, you can’t improve it.” It is considered a hallmark in business.

Currently, manufacturers are offering assorted air cleaning solutions that include the good, the bad, and the unhealthy. One question to ask prior to purchase: Do these technologies provide integrated monitoring of the air? Without monitoring the air, the application and functionality of the technology are immediately cast into doubt. For example, a UV-C lamp may lack the required exposure time required for disinfection. This is a bit analogous to running a large facility heating and cooling system with a window unit.

Obtaining reliable and tested systems that use high-efficiency particulate air (HEPA) and UV-C technology is one thing; application to achieve functionality (the proper selection of technology) is another. Without the ability to measure air quality, air improvement is subjective.

“In recognizing the nature of the airborne spread of COVID-19, it is paramount to establish and maintain an adequate level of indoor air quality,” Gary Shubinsky, PhD, the president and CEO of LightWave SensorTech LLC, a Chicago, Illinois–based technology company that engineers and manufactures advanced UV systems for IAQ, said in an interview with Infection Control Today^®13. “The correct path to achieve this level is only via an integrated system of complementary air management technologies, including a combination of airflow management, filtration, purification, and real-time monitoring.”

Consistent Performance

LightWave’s methodology is correct. A lasting air management solution will require proper engineering and not a pileup approach involving unproven products. One concern is that decision makers will fall into the nearsighted trap of selecting piecemeal products that require frequent maintenance, with inconsistent performance and low reliability. Essentially, the concern is about using a short-term Band-Aid solution for a long-term problem. Little, if any, improvement in the ability to supply healthy indoor air and face seasonal influenza or future pandemics will come of this approach. A holistic integrated IAQ solution, one that is informed and addresses core IAQ problems, is required. An integrated solution implies the use of complementary technologies across building management, and there are several elements involved.

This requires:

• an alignment of heating, ventilation, and air-conditioning system performance with building pressurization;
• air filtration requirements and a customizable safe air-purification system; and
• a network of air management sensors (differential pressure, carbon monoxide, carbon dioxide, thermal, moisture, and airflow) that supply real-time building analytics.

Combined, these parameters optimize cost, performance efficiency, and infection control for a lasting and consistently healthier quality of life. A solution where air quality can be quantified and improved will provide a healthy environment and a future ventilation solution. The ability to respond to current and future infection control concerns will be addressed, and the improved indoor air quality will be measurable. These solutions are obtainable, and the technology and services exist.

To get to this point, you need to look for a partner that is not just selling a HEPA filter or UV light but will provide a measurable understanding of indoor air quality and thus infection control within a building.

CEDRIC STEINER is a licensed nursing home administrator in Lancaster County, Pennsylvania, who has a specific interest in addressing infection control in the long-term care setting. Steiner is seeking partners for a webinar that he hopes will promote a holistic approach to indoor air management. Contact him at steiner@gshealthcare.org or @SteinerGS for integrated solutions and infection control concerns related to indoor air quality.

References:

1. Morawska L, Milton DK. It is time to address airborne transmission of coronavirus disease 2019 (COVID-19). Clin Infect Dis. 2020;71(9):2311-2313. doi:10.1093/cid/ciaa939
2. van Doremalen N, Morris DH, Holbrook MG, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. April 16, 2020. N Engl J Med. 2020; 382:1564-1567. doi:10.1056/NEJMc2004973
3. Nissen K, Krambrich J, Akaberi D, et al. Long-distance airborne dispersal of SARS-CoV-2 in COVID-19 wards. Sci Rep. 2020;10(1):19589. doi:10.1038/s41598-020-76442-2
4. Zaatari M, Harmon M. Open letter to address the use of electronic air cleaning equipment in buildings. April 12, 2020. Accessed May 9, 2021. https://medium.com/open-letter-to-address-the-use-of-electronic-air/no-to-ionizers-plasma-uvpco-bc1570b2fb9b
5. Coronavirus disease (COVID-19): how is it transmitted? World Health Organization. December 13, 2020. Updated April 30, 2021. Accessed May 15, 2021. https://www.who.int/news-room/q-a-detail/coronavirus-disease-covid-19-how-is-it-transmitted
6. Timothy Crouch. CLA Philadelphia. https://www.claconnect.com/directory/c/crouch-timothy
7. About us: people first places. Accessed June 3, 2021. International WELL Building Institute. https://www.wellcertified.com/about-iwbi/
8. Joshi SM. The sick building syndrome. Indian J Occup Environ Med. 2008;12(2):61-64. doi:10.4103/0019-5278.43262
9. JunHo Jo, ByungWan Jo, JungHoon Kim, SungJun Kim, WoonYong Han. Development of an IoT-based indoor air quality monitoring platform. Journal of Sensors. 2020:1-14. doi:10.1155/2020/8749764
10. DNA-powered verification for safety and traceability. SafeTraces. Accessed May 18, 2021. https://www.safetraces.com/
11. U.S. Department of Energy. (2021, April). Ventilation in Residential Care Environments. National Renewable Energy Laboratory. https://www.nrel.gov/docs/fy21osti/79150.pdf.
12. RHP Risk Management. Company website. Accessed June 1, 2021. https://rhprisk.com/ventilation/
13. LightWave SensorTech. Company website. Accessed June 1, 2021. https://www.lwtglobal.com/