Natural Ventilation of Health Care

Facilities
Engineering Methods for the Control of Airborne Infections: An
International Perspective

Harvard School of Public Health

20th July 2008

Dr Rod Escombe MD DTM&H PhD

Honorary Research Fellow, Wellcome Centre for Clinical Tropical Medicine & Department of
Infectious Diseases & Immunity, Imperial College London, UK.
Senior Investigator, Asociación Benéfica PRISMA, Lima, Perú.
GP Registrar, St Mary’s Hospital, London, UK. HOSPITAL
NACIONAL
“DOS DE MAYO”
HIV-TB MDR, XDR

1.Bonifacio N. Emerg Inf Dis 2002;8:747

2.Joshi R. PLoS Med 2006; 3:494
3.Drobniewski F. PLoS Med 2007; 4:55
 Ventilation and control of airborne
infection in health care facilities

• Dilutional ventilation is the

mainstay of environmental
control measures for
airborne infections

• Aim to reduce the

concentration of infectious
airborne particles

• Reduce exposure of
patients, staff and visitors
 Measuring ventilation:
Air Changes per Hour (ACH)
Fresh
air

100
=
80
Concentration (cfu/m3)

33:67%
60

40 1 ACH
2
20 4
8
0
0 1 2 3 4
Time (hours)

Effect of ACH on concentration of airborne particles

 Modelling effect of ventilation on
airborne infection

Wells-Riley equation:

C=S(1-e –Iqpt/Q)
C= new cases
S=susceptibles
I =number of infectors
q=infectious quanta produced per hour
p=pulmonary minute ventilation
t=duration of exposure
Q=absolute ventilation (= ACH x room volume)
Effect of dilutional ventilation on risk of
airborne infection

)
R is k

20 in
0.5 /m
nta
qua
(
10 tion
0 a
0 ner
10 ge
Ventilatio 20 ta
n rate (h- 300 n
1) ua
Q

Yuguo Li
 Mechanical ventilation

• Air changes dilute

infectious particles
• Negative pressure
• Standard of care

CDC Guidelines 2005: 6-12 ACH

for high-risk
areas
 Natural ventilation
• Passive supply of outdoor air to
a building interior for ventilation
and cooling
• Historically all buildings
employed natural ventilation

Pantheon, Rome – 120 AD

Natural ventilation in health care
facilities
“The very first canon of nursing, the
first and the last thing upon which a
nurse’s attention must be fixed, the
first essential to the patient, without
which all the rest you can do for him
is as nothing, with which I had
almost said you may leave all the
rest alone, is this: to keep the air he
breathes as pure as the external air,
without chilling him”

Notes on Nursing – What it is and what it is not. 1860. London

TB sanatoria
• Pre-antibiotic era
• Fresh air therapy
Midhurst, Sussex, UK
With modern building design, advent of HVAC,
natural ventilation fell from favour
 Renewed interest in
natural ventilation
General building design
• Need to reduce energy costs: “green buildings”

Health care facilities

• TB & HIV epidemics, emergence of drug
resistance and recognition of nosocomial spread1
• TB prevention low resource settings. WHO 19992
• TB Infection control in era of HIV. WHO 20073
• Infection prevention and control of epidemic- and
pandemic-prone acute respiratory diseases in
health care. WHO Interim guidelines 20074

Evidence base so far is slim

• Data from Peru
1. Gandhi, N.R., et al. XDR-TB in South Africa. Lancet, 2006. 368:1575-80.
2. http://www.who.int/docstore/gtb/publications/healthcare/PDF/WHO99-269.pdf World Health
3. http://whqlibdoc.who.int/hq/1999/WHO_TB_99.269_ADD_eng.pdf Organization
4. http://www.who.int/csr/resources/publications/WHO_CD_EPR_2007_6/en/
 Natural ventilation

• Simply opening windows

• Low cost
• Maintenance free
• Climate dependant
Natural ventilation – basic principles

Cross ventilation Stack effect

Hot air rises

Natural ventilation – basic principles
Layout

Poor Improved
WHO guidelines
Martin Yag
Paul Jensen
 Natural ventilation in Lima hospitals
• 8 hospitals
– 5 old-fashioned design built pre-1950
– 3 modern hospitals built 1970-90

• 70 naturally ventilated rooms

– Respiratory isolation rooms
– TB, respiratory, infectious disease, HIV, general medical wards
– Emergency departments
– Out-patient clinics and waiting rooms

• 12 mechanically ventilated respiratory

isolation rooms
– Built in 2000, renovated by Wellcome Trust in 2004