Date Published: February 27, 2007
Publisher: Public Library of Science
Author(s): A. Roderick Escombe, Clarissa C Oeser, Robert H Gilman, Marcos Navincopa, Eduardo Ticona, William Pan, Carlos Martínez, Jesus Chacaltana, Richard Rodríguez, David A. J Moore, Jon S Friedland, Carlton A Evans, Peter Wilson
Abstract: BackgroundInstitutional transmission of airborne infections such as tuberculosis (TB) is an important public health problem, especially in resource-limited settings where protective measures such as negative-pressure isolation rooms are difficult to implement. Natural ventilation may offer a low-cost alternative. Our objective was to investigate the rates, determinants, and effects of natural ventilation in health care settings.Methods and FindingsThe study was carried out in eight hospitals in Lima, Peru; five were hospitals of “old-fashioned” design built pre-1950, and three of “modern” design, built 1970–1990. In these hospitals 70 naturally ventilated clinical rooms where infectious patients are likely to be encountered were studied. These included respiratory isolation rooms, TB wards, respiratory wards, general medical wards, outpatient consulting rooms, waiting rooms, and emergency departments. These rooms were compared with 12 mechanically ventilated negative-pressure respiratory isolation rooms built post-2000. Ventilation was measured using a carbon dioxide tracer gas technique in 368 experiments. Architectural and environmental variables were measured. For each experiment, infection risk was estimated for TB exposure using the Wells-Riley model of airborne infection. We found that opening windows and doors provided median ventilation of 28 air changes/hour (ACH), more than double that of mechanically ventilated negative-pressure rooms ventilated at the 12 ACH recommended for high-risk areas, and 18 times that with windows and doors closed (p < 0.001). Facilities built more than 50 years ago, characterised by large windows and high ceilings, had greater ventilation than modern naturally ventilated rooms (40 versus 17 ACH; p < 0.001). Even within the lowest quartile of wind speeds, natural ventilation exceeded mechanical (p < 0.001). The Wells-Riley airborne infection model predicted that in mechanically ventilated rooms 39% of susceptible individuals would become infected following 24 h of exposure to untreated TB patients of infectiousness characterised in a well-documented outbreak. This infection rate compared with 33% in modern and 11% in pre-1950 naturally ventilated facilities with windows and doors open.ConclusionsOpening windows and doors maximises natural ventilation so that the risk of airborne contagion is much lower than with costly, maintenance-requiring mechanical ventilation systems. Old-fashioned clinical areas with high ceilings and large windows provide greatest protection. Natural ventilation costs little and is maintenance free, and is particularly suited to limited-resource settings and tropical climates, where the burden of TB and institutional TB transmission is highest. In settings where respiratory isolation is difficult and climate permits, windows and doors should be opened to reduce the risk of airborne contagion.
Partial Text: Infections transmitted by the airborne route are leading causes of morbidity and mortality worldwide, with tuberculosis (TB) alone causing 1.8 million deaths each year . Outbreaks occur in prisons [2,3], homeless shelters [4,5], and schools , but it is health care facilities that may pose the greatest risk from airborne contagion by congregating infectious and susceptible individuals, resulting in frequent airborne nosocomial transmission [7–11]. This public health problem is exacerbated by HIV infection, which increases both susceptibility and hospitalisation.
We found that natural ventilation created by opening windows and doors provided high rates of air exchange, absolute ventilation, and theoretical protection against airborne TB infection. These factors were greatest in facilities built more than 50 years ago, even on days with little wind. In contrast, modern mechanically ventilated rooms had poor absolute ventilation even at recommended air exchange rates for high-risk areas, and consequently had higher estimated risks of airborne contagion.