Abstract
Aerial dispersion of human exhaled microbial contaminants and subsequent contamination of surfaces is a potential route for infection transmission in hospitals. Most general hospital wards have ventilation systems that drive air and thus contaminants from the patient areas towards the corridors. This study investigates the transport mechanism and deposition patterns of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) within a typical six bedded general inpatient ward cubicle through numerical simulation. It demonstrates that both air change and exhaust airflow rates have significant effects on not only the airflow but also the particle distribution within a mechanically ventilated space. Moreover, the location of an infected patient within the ward cubicle is crucial in determining the extent of infection risk to other ward occupants. Hence, it is recommended to provide exhaust grilles in close proximity to a patient, preferably above each patient’s bed. To achieve infection prevention and control, high exhaust airflow rate is also suggested. Regardless of the ventilation design, all patients and any surfaces within a ward cubicle should be regularly and thoroughly cleaned and disinfected to remove microbial contamination. The outcome of this study can serve as a source of reference for hospital management to better ventilation design strategies for mitigating the risk of infection.
Keywords: ventilation, bioaerosol dispersion, indoor air quality (IAQ), infection risk, hospital general ward, computational fluid dynamics (CFD)
Acknowledgements
This work was partially supported by the Research Grants Council of HKSAR and The Hong Kong Polytechnic University (Project No. 15208817E).
References
- ANSYS . Ansys Fluent 13.0 Documentation. Lebanon, NH, USA: Ansys Inc.; 2010. [Google Scholar]
- ASHRAE . ASHRAE Standard. Ventilation for Health Care Facilities. Atlanta, GA, USA: American Society of Heating, Refrigerating and Air-Conditioning Engineers; 2013. [Google Scholar]
- ASHRAE . ASHRAE Fundamentals SI Handbook. Atlanta, GA, USA: American Society of Heating, Refrigerating and Air-Conditioning Engineers; 2013. [Google Scholar]
- Beggs CB, Kerr KG, Noakes CJ, Hathway EA, Sleigh PA. The ventilation of multiple-bed hospital wards: Review and analysis. American Journal of Infection Control. 2008;36:250–259. doi: 10.1016/j.ajic.2007.07.012. [DOI] [PubMed] [Google Scholar]
- Blocken B. LES over RANS in building simulation for outdoor and indoor applications: a foregone conclusion? Building Simulation. 2018;11:821–870. [Google Scholar]
- Bolashikov Z, Melikov A, Kierat W, Popiołek Z, Brand M. Exposure of health care workers and occupants to coughed airborne pathogens in a double-bed hospital patient room with overhead mixing ventilation. HVAC & R Research. 2012;18:602–615. [Google Scholar]
- Chao CYH, Wan MP, Sze To GN. Transport and removal of expiratory droplets in hospital ward environment. Aerosol Science and Technology. 2008;42:377–394. [Google Scholar]
- Chaudhury H, Mahmood A, Valente M. Advantages and disadvantages of single-versus multiple-occupancy rooms in acute care environments: A review and analysis of the literature. Environment and Behavior. 2005;37:760–786. [Google Scholar]
- Chen Q. Comparison of different k-ε models for indoor air flow computations. Numerical Heat Transfer, Part B: Fundamentals. 1995;28:353–369. [Google Scholar]
- Chen C, Zhao B, Yang X, Li Y. Role of two-way airflow owing to temperature difference in severe acute respiratory syndrome transmission: Revisiting the largest nosocomial severe acute respiratory syndrome outbreak in Hong Kong. Journal of the Royal Society Interface. 2011;8:699–710. doi: 10.1098/rsif.2010.0486. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Duguid JP. The size and the duration of air-carriage of respiratory droplets and droplet-nuclei. Journal of Hygiene. 1946;44:471–479. doi: 10.1017/s0022172400019288. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Gao NP, Niu JL. CFD study of the thermal environment around a human body: A review. Indoor and Built Environment. 2005;14:5–16. [Google Scholar]
- Ghia U, Konangi S, Kishore A, Gressel M, Mead K, Earnest G. Assessment of health-care worker exposure to pandemic flu in hospital rooms. ASHRAE Transactions. 2012;118(1):442–449. [PMC free article] [PubMed] [Google Scholar]
- Giannini MA, Nance D, McCullers JA. Are toilet seats a vector for transmission of methicillin-resistant Staphylococcus aureus? American Journal of Infection Control. 2009;37:505–506. doi: 10.1016/j.ajic.2008.11.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Gralton J, Tovey E, McLaws ML, Rawlinson WD. The role of particle size in aerosolised pathogen transmission: A review. Journal of Infection. 2011;62:1–13. doi: 10.1016/j.jinf.2010.11.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Hang J, Li Y, Jin R. The influence of human walking on the flow and airborne transmission in a six-bed isolation room: Tracer gas simulation. Building and Environment. 2014;77:119–134. doi: 10.1016/j.buildenv.2014.03.029. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Humphreys H. Overcrowding, understaffing and infection in hospitals. Irish Medical Journal. 2006;99:102. [PubMed] [Google Scholar]
- Kim SH, Chang SY, Sung M, Park JH, Bin Kim H, Lee H, Choi JP, Choi WS, Min JY. Extensive viable middle east respiratory syndrome (MERS) coronavirus contamination in air and surrounding environment in MERS isolation wards. Clinical Infectious Diseases. 2016;63:363–369. doi: 10.1093/cid/ciw239. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Lai ACK, Wong LT, Mui KW, Chan WY, Yu HC. An experimental study of bioaerosol (1–10 (µm) deposition in a ventilated chamber. Building and Environment. 2012;56:118–126. [Google Scholar]
- Li Y, Huang X, Yu ITS, Wong TW, Qian H. Role of air distribution in SARS transmission during the largest nosocomial outbreak in Hong Kong. Indoor Air. 2005;15:83–95. doi: 10.1111/j.1600-0668.2004.00317.x. [DOI] [PubMed] [Google Scholar]
- Li Y, Leung GM, Tang JW, Yang X, Chao CYH, Lin JZ, Lu JW, Nielsen PV, Niu J, Qian H, Sleigh AC, Su HJJ, Sundell J, Wong TW, Yuen PL. Role of ventilation in airborne transmission of infectious agents in the built environment—A multidisciplinary systematic review. Indoor Air. 2007;17:2–18. doi: 10.1111/j.1600-0668.2006.00445.x. [DOI] [PubMed] [Google Scholar]
- Li Y, Tang J, Noakes C, Hodgson MJ. Engineering control of respiratory infection and low-energy design of healthcare facilities. Science and Technology for the Built Environment. 2015;21:25–34. [Google Scholar]
- Licina D, Melikov A, Pantelic J, Sekhar C, Tham KW. Human convection flow in spaces with and without ventilation: Personal exposure to floor-released particles and cough-released droplets. Indoor Air. 2015;25:672–682. doi: 10.1111/ina.12177. [DOI] [PubMed] [Google Scholar]
- Memarzadeh F, Xu W. Role of air changes per hour (ACH) in possible transmission of airborne infections. Building Simulation. 2012;5:15–28. doi: 10.1007/s12273-011-0053-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Nicas M, Hubbard AE, Jones RM, Reingold AL. The infectious dose of variola (smallpox) virus. Applied Biosafety. 2004;9:118–127. [Google Scholar]
- Nielsen PV. Fifty years of CFD for room air distribution. Building and Environment. 2015;91:78–90. [Google Scholar]
- Oh MD, Park WB, Park SW, Choe PG, Bang JH, Song KH, Kim ES, Kim HB, Kim NJ. Middle East respiratory syndrome: What we learned from the 2015 outbreak in the Republic of Korea. Korean Journal of Internal Medicine. 2018;33:233–246. doi: 10.3904/kjim.2018.031. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Pantelic J, Tham KW. Adequacy of air change rate as the sole indicator of an air distribution system’s effectiveness to mitigate airborne infectious disease transmission caused by a cough release in the room with overhead mixing ventilation: A case study. HVAC&R Research. 2013;19:947–961. [Google Scholar]
- Qian H, Li Y. Removal of exhaled particles by ventilation and deposition in a multibed airborne infection isolation room. Indoor Air. 2010;20:284–297. doi: 10.1111/j.1600-0668.2010.00653.x. [DOI] [PubMed] [Google Scholar]
- Roache PJ. Verification of codes and calculations. AIAA Journal. 1998;36:696–702. [Google Scholar]
- Roy CJ, Milton DK. Airborne transmission of communicable infection—the elusive pathway. New England Journal of Medicine. 2004;350:1710–1712. doi: 10.1056/NEJMp048051. [DOI] [PubMed] [Google Scholar]
- Shen C, Gao N, Wang T. CFD study on the transmission of indoor pollutants under personalized ventilation. Building and Environment. 2013;63:69–78. [Google Scholar]
- Tang JW, Wilson P, Shetty N, Noakes CJ. Aerosol-transmitted infections—A new consideration for public health and infection control teams. Current Treatment Options in Infectious Diseases. 2015;7:176–201. doi: 10.1007/s40506-015-0057-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Tian L, Lin Z, Wang Q, Liu J. Numerical investigation of indoor aerosol particle dispersion under stratum ventilation and under displacement ventilation. Indoor and Built Environment. 2009;18:360–375. [Google Scholar]
- Van Doremalen N, Bushmaker T, Munster VJE. Stability of Middle East respiratory syndrome Coronavirus (MERS-CoV) under different environmental conditions. Euro Surveillance. 2013;18:20590. doi: 10.2807/1560-7917.es2013.18.38.20590. [DOI] [PubMed] [Google Scholar]
- Wan MP, Chao CYH, Ng YD, Sze To GN, Yu WC. Dispersion of expiratory droplets in a general hospital ward with ceiling mixing type mechanical ventilation system. Aerosol Science and Technology. 2007;41:244–258. [Google Scholar]
- Wells WF. Airborne Contagion and Air Hygiene. An Ecological Study of Droplet Infections. Cambridge, USA: Harvard University Press; 1955. [Google Scholar]
- Wong LT, Chan WY, Mui KW, Lai ACK. An experimental and numerical study on deposition of bioaerosols in a scaled chamber. Aerosol Science and Technology. 2010;44:117–128. [Google Scholar]
- Wong LT, Yu HC, Mui KW, Chan WY. Drag constants for common indoor bioaerosols. Indoor and Built Environment. 2015;24:401–413. [Google Scholar]
- Xiao S, Li Y, Sung M, Wei J, Yang Z. A study of the probable transmission routes of MERS-CoV during the first hospital outbreak in the Republic of Korea. Indoor Air. 2018;28:51–63. doi: 10.1111/ina.12430. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Xie X, Li Y, Chwang ATY, Ho PL, Seto WH. How far droplets can move in indoor environments—revisiting the Wells evaporation-falling curve. Indoor Air. 2007;17:211–225. doi: 10.1111/j.1600-0668.2007.00469.x. [DOI] [PubMed] [Google Scholar]
- Yu HC, Mui KW, Wong LT, Chu HS. Ventilation of general hospital wards for mitigating infection risks of three kinds of viruses including Middle East respiratory syndrome coronavirus. Indoor and Built Environment. 2017;26:514–527. [Google Scholar]
- Zeytounian RK. Joseph Boussinesq and his approximation: A contemporary view. Comptes Rendus Mécanique. 2003;331:575–586. [Google Scholar]
- Zhang Z, Chen Q. Experimental measurements and numerical simulations of particle transport and distribution in ventilated rooms. Atmospheric Environment. 2006;40:3396–3408. [Google Scholar]
- Zhang Z, Chen Q. Comparison of the Eulerian and Lagrangian methods for predicting particle transport in enclosed spaces. Atmospheric Environment. 2007;41:5236–5248. [Google Scholar]
- Zhang Z, Zhang W, Zhai ZJ, Chen QY. Evaluation of various turbulence models in predicting airflow and turbulence in enclosed environments by CFD: part 2—comparison with experimental data from literature. HVAC&R Research. 2007;13:871–886. [Google Scholar]
- Zhao B, Zhang Y, Li X, Yang X, Huang D. Comparison of indoor aerosol particle concentration and deposition in different ventilated rooms by numerical method. Building and Environment. 2004;39:1–8. [Google Scholar]
- Zumla A, Hui DS, Perlman S. Middle East respiratory syndrome. The Lancet. 2015;386:995–1007. doi: 10.1016/S0140-6736(15)60454-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
