Word on the Street    

Nine-Year-Old TB Guidelines Revised

IAQ in Schools- Unplanned Air Flows and Poor IAQ In Vo-Tech Schools

IAQ In Health - Acceptable Fungi, Bacteria levels in Hospitals  

Improving IAQ At The Source Greenguard Program Certifying Products for Low Emissions

Indoor air pollution is recognized as one of the greatest risks to public health by such organizations as the U.S. Environmental Protection Agency, the American Lung Association and the World Health Organization. Poor indoor air quality can lead to allergies, asthma, reproductive and developmental problems and cancer. The economic impact of indoor air pollution is equally alarming.

Poor IAQ can also adversely affect occupant health and productivity. Numerous studies have estimated these costs to U.S. businesses to be in the tens of billions of dollars per year. Improvements in the indoor air environment may substantially increase employee moral and productivity and reduce healthcare costs.

The most effective way to prevent IAQ crises and achieve and maintain good indoor environments is to implement an IAQ management plan that addresses all factors potentially impacting IAQ. Controlling emissions from construction materials, indoor furnishings and processes such as cleaning and operation of office equipment (source control) is one of the more daunting elements of such an IAQ management plan.

In the past, the only way to obtain information about low emitting products and materials was to ask the manufacturers. Unfortunately, the lack of product definition and uniform testing and performance requirements have left their marketing claims confusing and unsubstantiated. To date, there are no federal, state, or local regulations that control product emissions. Some states and federal agencies, including the State of Washington and the EPA, set purchasing requirements for their own facilities but shy away from universally applicable IAQ standards. The carpet industry was required to establish an IAQ labeling program in the early 1990s as a result of the carpet policy dialogue. The program, which is administered by the industry’s trade association, was successful in controlling and reducing volatile organic compound emissions from carpet and associated material. However, the program does not have established third party oversight or performance verification procedures.

The U.S. Green Building Council recognized IAQ as a major part of green buildings in its Leadership for Energy and Environmental Design program. IAQ accounts for 23 percent of all credits in LEED, but more work is needed as current scorings are based heavily on chemical content and not actual tested or verified chemical emissions. Many credits focus on components and content of products and materials rather than on their actual emissions. Therefore, the effect on building occupants and indoor environments remains unaddressed. The council had to focus on material content when the LEED program was developed due to the lack of third-party IAQ certification programs at that time. In the summer of 2002, however, the council introduced a pilot of LEED for Commercial Interiors, requiring furniture and furnishings to be tested for volatile organic compound emissions, including formaldehyde.

History Of Greenguard
The Greenguard certification program was founded to fill the void, establishing a true third-party certification based on proven emissions standards and providing specifying and procurement professionals with a resource for low-emitting products. The program evolved out of the original AQSpec list program developed by Marilyn Black, Ph.D., and Air Quality Sciences Inc. in 1996. The original AQSpec list program was established to identify those manufacturers and products that had been found to meet the general product emissions standards established by the State of Washington and the office furniture emissions standard established by the EPA for its headquarters’ project.

Originally, it was simply a registry or listing of products that had been tested following specific test protocols and found to meet the EPA and Washington emissions standards. There was no intended control over selection and handling of the products, age of the products, consistency of the performance over time or manufacturing variability.

In June 2000, the Greenguard registry program replaced the AQSpec list. In an effort to provide builders, architects, interior designers, building owners and consumers with a free resource for selecting low-emitting products and to inform the public about indoor air quality issues, AQS began publishing the Greenguard Registry online. However, the many consumer and user questions related to manufacturing claims and verification of emissions performance led AQS to the conclusions that it was not enough simply to test products one time and publish low-emissions results. A true third-party, nonprofit organization was needed to establish procedures, protocols and verification processes independent from industry or monetary interests.

In June 2001, the Greenguard Environmental Institute was founded to oversee the emissions in a realistic manner similar to the way the product would emit in a building.

Environmental chamber testing allows the wide spectrum of VOC emissions to be determined rather than just the primary components of the product. Many times, the primary components of a product are not the primary sources of volatile emissions from a product. Frequently, the reaction byproducts of the primary components or contaminants in the primary components comprise the majority of the volatile emissions from a product. Environmental chamber testing emissions data can be mathematically modeled to determine exposure concentrations produced by the use of the product in many different indoor environments. Modeling of a product’s emission data allows the product use to be evaluated for health, irritation and odor concerns for a wide range of indoor environments. The product is tested at the same loading ratio of exposed surface area to room volume, as found in a typical indoor environment. This way, the results of chamber testing are scalable to any size room.

Program Benefits
The benefits of a program such as Greenguard to the public are many. The Greenguard Indoor Air Quality Certified seal provides an easy way for building managers, construction, design and procurement professionals to identify low-emitting products and materials for their projects without incurring any extra effort or cost. Additionally, the GEI helps promote awareness of IAQ issues and good IAQ management through presentations, white papers, articles and other general education mechanisms.

Greenguard certification offers huge benefits to product manufacturers, too. Currently, few manufacturers are attentive to their products’ emissions. Those who are attentive can secure future sales growth by tapping into the green building market, one of the fastest growing markets worldwide. Greenguard certification provides a public, scientifically based, third-party qualification for manufacturers’ products and services. Once manufacturers are certified, they can label their products with the Greenguard Indoor Air Quality Certified mark and list them in the free online Greenguard Product Guide.

In addition, the ongoing tests can provide manufacturers with a window they never had before into the chemical compositions of their own products and that of their suppliers’ products. The GEI encourages suppliers to also become Greenguard certified. This will ensure consistent quality, design, development and distribution of indoor environmentally preferred products. Finally, companies that demonstrate their commitment to public health and indoor environments by producing better, safer products can bolster their public relations and public image as general awareness of IAQ issues continues to grow.

Henning M. Bloech is director of communications for the Greenguard Environmental Institute, the nonprofit organization overseeing the Greenguard certification program, the only independent testing program for low-emitting products and materials. Access to the Greenguard Product Guide is provided free of charge at www.greenguard.org. You can reach Bloech by e-mail at hbloech@greenguard.org or by phone at (800)427-9681.   

Word on the Street

• Voices: “And now, here to present their opposition to the indoor air quality bill... Wait a minute, does that mean you’re in favor of dirty air?”
  —Paula C. Hollinger, chair of the Maryland Senate’s Education,Health and Environmental Affairs Committee, in a jocular mood at a March 4 hearing on Senate Bill 592
      
• No Money For Mold:  A fiscal note issued last month indicated that substantial costs would be incurred if the Texas Legislature were to pass Senate Bill 129, which calls for the licensure of mold assessment and remediation professionals. The promise of substantial costs generally dooms bills in the current legislative climate. Texas, like most U.S. states, is battling a budget deficit.
    
• Offshore Cleaning: DUCTBUSTERS of Louisiana Inc. recently evaluated, cleaned and coated the air conditioning ductwork on six Noble rigs off the coast of Nigeria. Keith Blanchard, president of DUCTBUSTERS, explained the value of the contract. “DUCTBUSTERS is pleased to have been selected to perform an indoor air quality inspection and provide HVAC cleaning services to improve air quality in the working and living environments on these rigs in international waters. This reflects Noble’s confidence in DUCTBUSTERS’ capabilities and technologies to provide the most state-of-the-art equipment and experienced technicians in the industry.”
    
• Blue Ribbon Selection: Mark DeLisle CEO of DeLisle Associates LTD has been nominated and selected by Region 5 of the Environmental Protection Agency to sit on a Blue Ribbon Commission to developed a report of needed regulatory changes on the current asbestos laws, rules and regulations in the United States. After the report is completed, EPA will then submit it to Congress.
    
• Crawling With Dust: More than 80 percent of homes in America have detectable levels of house dust mite, the microscopic critter that triggers dust allergies, a team of Massachusetts and Washington, DC, researchers report in the first national study on the topic. Studies have shown that people who are allergic to dust mites may be at risk of developing asthma, a condition that has been on the rise in the U.S. since 1980. 
     
  “Our study indicates that most people in the U.S. can assume that they have some exposure to dust mite allergen in their homes,” Dr. Samuel J. Arbes Jr. at the National Institute of Environmental Health Sciences in Research Triangle Park, N.C., told Reuters Health. 
    
  Based on data from the National Survey of Lead and Allergens in Housing, which included 831 randomly selected households, Arbes and his colleagues found that 84 percent of U.S. homes had detectable levels of dust mite allergen in a bed.
  
• Request Denied: The Maryland Insurance Administration has denied an insurance industry request to exclude mold from homeowner and commercial policies but agreed to limit the coverage for the first time. The agency ruled late in March that insurance companies may limit mold removal coverage to $15,000 and liability to $50,000. The state previously placed no limit on mold claims. Insurance companies had pushed for a full exclusion in the state, saying rising claims nationwide have increased premiums during the past few years.
    
• Apartments Get Help: The issue of indoor air quality, long a concern primarily in the office sector, has evolved into a major legal and public policy issue in the apartment sector. To help apartment firms address this issue, the National Multi-Housing Council and National Apartment Association have published a new members only White Paper entitled Beyond Mold: Managing Indoor Air Quality.
     
  The paper covers a wide range of IAQ issues, including: environmental tobacco smoke, pesticides, carbon monoxide and volatile organic compounds.
  It explores various IAQ pollutants and reviews relevant litigation and insurance issues, potential liability issues facing property owners and existing federal and state IAQ legislation.
    
  “Apartment resident concern over indoor air quality has grown significantly in recent years as consumer concern over mold in all indoor environments has became widespread,” explained Eileen Lee, NMHC/NAA’s Vice President of Environment. “As Americans’ environmental awareness has grown, it has created a new awareness among apartment residents about other IAQ issues beyond mold.”
    
• Air Fraud? According to the Sacramento Bee newspaper, Ground Zero tests by the U.S. Environmental Protection Agency in the days immediately after the World Trade Center collapse did not support the agency’s own statements the air around the site was safe to breathe.
     
  A report by the EPA’s Office of Inspector General said the agency reached its conclusion on the safety of the air using a cancer risk level 100 times greater than what it normally considers acceptable for public exposure to toxic contaminants.
    
  The status report, obtained by the Bee, supports the views of some doctors and public health advocates who evaluated thousands of firefighters, volunteers, demolition workers and laborers working on the site.
  “To say that it’s safe, which suggests no risk, we just knew that was wrong,” said Jonathan Bennett, a spokesman for the New York Committee for Occupational Safety and Health.
    
  The status report summarizes preliminary conclusions. It is expected to be published next month and a spokesman for the inspector general said the findings could change before publication. The Office of Inspector General is an independent investigative office that reports directly to Congress.
    
  EPA officials claim the newspaper report confused health warnings the agency gave to workers with reassurances it gave the public. It also misinterprets what the agency warned were short- and long-term health effects from the cleanup.
    
• Weighing In On UV: Ultraviolet light can be an effective agent for killing microbial aerosols, according to a recent report of the Air-Conditioning and Refrigeration Technology Institute.
    
  “During this research, UVGI [ultraviolet germicidal irradiation] lamps were experimentally demonstrated to inactivate bioaerosols comprised of vegetative bacteria, bacteria spores, or fungal spores to a reproducible degree under conditions of fixed dose,” according to authors Douglas VanOsdell and Karin Foarde.
     
  The landmark research was sponsored under the ARTI 21-CR program funded by a consortium that included US DOE. The document, Defining the Effectiveness of UV Lamps Installed in Circulating Air Ductwork, is available to the public from the U.S. Department of Commerce.

Guidelines governing the prevention, control, diagnosis and treatment of tuberculosis have been completely revised for the first time since 1994. First published in 1971, the jointly developed guidelines are intended to advise both public health programs and health care providers in all aspects of the clinical and public health management of tuberculosis, or TB, in low-incidence countries. 

The revision of the TB guidelines was announced last month by the U.S. Centers for Disease Control and Prevention, the Infectious Diseases Society of America, and the American Thoracic Society, which stated in a press release that although experts believe that about 10 million Americans are infected with TB germs, only about 10 percent of them will develop TB disease in their lifetime. The other 90 percent will never get sick from TB or be able to spread the disease to other people. 

TB is a growing problem throughout the world, especially in Africa where the spread is facilitated by AIDS, the society press release stated. It is estimated that by 2020, nearly 1 billion people worldwide will become infected, 200 million will become sick, and 70 million will die. 

The new guidelines focus on the latest aspects of therapy, including drug administration, the use of fixed-dose combination preparations, the monitoring and management of adverse effects and drug interaction. Directly observed therapy is advised for patients because of the higher rates of treatment completion. 

The document recommends four regimens for treating patients with tuberculosis caused by drug-susceptible organisms. Each regimen has an initial phase of two months followed by the choice of several options for the continuation period of four to seven months. 

In these newly revised guidelines, for the first time, regimens recommended for the treatment of TB are based on the strength of the scientific evidence supporting their use. In addition, the responsibility for successful treatment is now clearly assigned to the public health program or private provider, not to the patient. Furthermore, treatment completion is defined by the number of doses ingested, as well as by the duration of treatment administration. 

The guidelines recommend that all patients with tuberculosis have counseling and testing for HIV infection by the time treatment is initiated, if not earlier. 

The document notes that the management of HIV-related tuberculosis is complex and requires expertise in the management of both HIV disease and tuberculosis. Management by experts is especially important since HIV patients often take numerous medications, some of which interact with anti-tuberculosis drugs. 

During treatment, the guidelines call for microscopic examination of a sputum culture at a minimum of monthly intervals until two consecutive specimens are negative. The guidelines comment that 80 percent of the patients with drug-susceptible organisms who are started on standard four-drug therapy will have a negative culture at two months. Patients with a positive culture after that time should undergo careful evaluation to determine the cause. For those not involved in directly observed therapy, the most common cause of a positive culture is nonadherence to treatment. 

With regard to children, the guidelines point out that there is a high risk of disseminated TB in infants and children less than 4 years old. Therefore, treatment should be started as soon as the diagnosis of TB is suspected. In general, the regimens recommended for adults are those of choice for infants, children and adolescents. However, one drug called ethambutol is not routinely given to children. Since young persons have a lower bacillary burden, there is less concern that they might develop acquired drug resistance. Directly observed therapy should always be used in treating children. 

In pregnant women with suspected TB, because of the risk of the disease being passed to the fetus, treatment should be initiated whenever the probability of disease in the mother is moderate to high. All of the drugs currently recommended do cross the placenta, however, they appear not to have teratogenic effects, according to the guidelines. Streptomycin is the only anti-tuberculosis drug documented to have harmful effects on the human fetus, causing congenital deafness. 

Most relapses after treatment occur within the first six to 12 months after completion of therapy. The selection of empirical treatment for patients with relapse should be based on the prior treatment scheme and the severity of disease.
   

It has pretty much become an expected pattern to my staff and me that occupants of “clean” classroom space in vocational schools will be complaining of movement of odors from the dirty areas into the clean classroom areas. It has been our experience that the movement of the dirty air (from the auto shops, welding labs, and other spaces associated with dusts and fumes) to clean areas, is almost universally caused by unplanned airflow. This may seem like common sense to most of the readers. After all, no one certainly ever planned on moving the dirty air to the clean areas, did they?

So, why the unplanned airflow? There has been one common thread in almost all of the problem facilities that we have worked with over the years, regardless of the type of structure, building vintage or campus layouts: Most had classroom spaces locates above technical shops. The occupants of the clean areas (offices and classrooms) located above the dirty areas of these schools have often reported health complaints and irritation associated with exposures to noxious emissions from shop activities which routinely occurred at the facilities as part of the normal curriculum.

Results of comprehensive HVAC and IAQ diagnostics revealed a common theme to be causing the complaints and health concerns. Simply stated, the overall building and envelope design, and the resulting unplanned airflows (usually caused by exhaust without make-up air) made it impossible for conventional HVAC systems in clean areas to prevent the migration of emissions from dirty shop areas effectively. These dirty shop areas were either located on the first floor (with classroom and office areas located on upper levels), or in some cases, they were located a significant distance away.

The specific causes of these failures involved the interaction of the actual distribution of total supply air in the areas of interest, the actual delivery of outdoor air (make-up air) to the ventilation systems and occupied areas, the controls of the ventilating units, the actual pressure relationships between dirty and clean areas of the facility and across the building shell, or the available fan capacity of the installed equipment to effect sufficient intrazonal pressure changes within the building shell.

In all cases, building diagnostics revealed pollutant pathways that would have been expected to lead to the reported intermittent occupant exposures in the clean areas. It would be expected that these exposures would lead to the reported dissatisfaction with the air quality and contribute to the reported health concerns. Although the identified problems leading to contaminate transport and staff exposures in each facility were different, the overall driving mechanisms that caused the pollutant transport to occur were very similar. Let’s look at some examples.

Building A
A review of the history of the building revealed that it was a 15-year old, 40,000-square foot, pre-engineered metal structure enclosing a two story classroom section and a high bay garage separated by a concrete block wall. The garage was utilized to teach heavy diesel mechanics. The entire facility was served by one large roof-mounted 100-percent outdoor air ventilation unit, equipped with air to air heat recovery and a bypass damper for economizer cooling. Convective baseboard and fan coils were utilized for heating. Classroom windows were operable casement type.

Significant results of diagnostic procedures revealed that: Intrazonal pressure relationships between the entire classroom and office area were negative with respect to the shop area. It also revealed inadequate rates of outdoor air supply to the classroom and office areas, historic cross contamination and leakage between dirty exhaust air from the shop and supply air to the classroom areas due to inherit design and construction of the HRV, inadequate rates of general exhaust and local vehicle tailpipe exhaust from the shop areas for program needs, inappropriate control locations for the vehicle tailpipe exhaust system, and unacceptable fan noise for teaching space, which prevented normal voice communication and thereby reduced use.

The problems could be fixed using some corrective actions. Rebalancing of the supply and exhaust air distribution was undertaken immediately to create minimum pressure differences between the two-story classroom area and the high bay garage. A bank of four large exhaust fans for the garage was added. The tailpipe exhaust fans for the garage were added. Finally, recommendations were made for the eventual addition of another HRV unit for the shop to provide more base level ventilation.

Building B
A review of the history of the building revealed that it was a 22-year-old, 50,000-square foot, metal-framed, brick-veneer, two-story structure built on six levels on a hillside. The high bay shops were located on the lower tier of the hill, with second-story classroom areas nested in the core of each high bay shop area on the three lower tiers. The shops were utilized to teach auto body, auto mechanics, wood working, etc. The entire facility was heated by electric resistance heat. Ventilation was provided by a mixture of three HVAC multi-zone units, one HV unit, 12 unit ventilators and many exhaust fans located on the roof.

Significant results of diagnostic procedures revealed that intrazonal pressure relationships of the upper floors of all of the classroom and office areas operated at negative pressures with respect to the shop areas below. Other revelations were the inadequate rates of outdoor air supplied to the classroom and office areas, that a historic shortage of maintenance funds and increases in electricity costs led to abandonment of some ventilation systems, inadequate rates of general exhaust from the shop areas for program needs, inappropriate control settings for air economizers severely limited the quantities of outdoor air that could be delivered to the “clean” non-shop areas, and an extremely leaky building shell existed on all six levels, with very leaky interior dividing walls.

This one was not as easy, but there were corrective actions. Isolation of the clean classroom areas from the dirty shop areas through attempts to eliminate intrazonal leakage provided only limited pollutant transport reduction due to the difficulty of the leaky building shell and many inaccessible roof/wall joints that could just not be made air tight. Costly recommendations were made to provide adequate make-up air to the clean areas by replacing abandoned systems: adequate exhaust to shop; and wall sealing were made.

Building C
A review of the history of the building revealed that it was a 13-year-old, 43,000-square foot, metal-framed, brick-veneer, two-story structure with several high bay shops attached to a three-story, 68-year-old much larger brick and block structure. The high bay shops were located on the located on the lower levels, with second-story classroom areas located above interior areas and in the perimeter area. The shops were utilized to teach auto body, auto mechanics, welding, wood working, etc. The entire facility was heated by steam boilers. Ventilation was provided to the vocational wing by a mixture of ceiling mounted noisy unit ventilators with ducted outdoor air with many exhaust fans located on several rooftop levels. The older three-story classroom wing was heated by perimeter steam radiators and ventilated by functional gravity shafts located in most classrooms and by a few unit ventilators.

Significant results of diagnostic procedures revealed intrazonal pressure relationships between all the upper floors of the classrooms and office at negative pressures with respect to the shop areas below, inadequate rates of outdoor air supplied to some of the interior vocational areas, very unacceptable noise from the ceiling-mounted unit ventilators that caused speech interference for classroom activities and led to predominantly little use of the installed ventilation equipment, inadequate rates of general exhaust from the shop areas for program needs. Finally, frequently vandalized temperature controls in the older three-story classroom wing led to overheating and the consequent use of open windows for temperature control, increasing the stack effect, and increasing pollutant transport between the attached facilities.

This one took some time, but the following corrective actions were fulfilled. The school has adopted a program to implement short-term fixes to provide adequate exhaust and ventilation for core areas and noise reduction on existing equipment. Also, a feasibility study has been commissioned to determine alternates for isolation of the vocational emissions from the three-story wing and to provide a long term upgrade of the entire ventilation and heating system of both buildings.

Common Fixes
It’s the intrazonal pressures that count. It can be safely hypothesized that the poor exhaust and observed intrazonal pressure relationships in the three facilities led to occupant exposures in the clean areas exacerbating occupant complaints, and leading to a concern for their health and well-being. Certainly, the conditions observed in all of the buildings would be, at best, very irritating, uncomfortable and frustrating.

By following a comprehensive, standardized diagnostic procedures including building intrazonal pressure quatification, we were able to uncover an overall picture of the IAQ/HVAC issues that contributed to the situation, such that remedial action could be evaluated and recommended.

The key fact remains: It appears that the fundamental issue of unwanted pollutant transport caused by unplanned airflow due to a strong “natural stack effect, or strong exhaust systems” may have not been understood or considered in the original design of these facilities. It is also possible that program needs regarding space utilization were in conflict with it the pressures that the natural stack effect would foster in the facility.

Just like gravity wins in a water drainage plane, stack effect wins in the long-term pressure relationship in a building, unless fan powered pressure control is overpowering it. Sealing between spaces alone is seldom if ever sufficient.

To minimize problems in new designs or in existing situations, there are some basic concepts that can help.

Provide make-up air in each zone that at least comes close to matching the exhaust, even if the exhaust flow is only sporadic, such as a large paint booth or culinary hoods. This will prevent the large exhausts from pulling air from far away places in the facility, cascading it from one room to another.

If the “dirty” vocational areas are simply attached to an adjoining building, attempt to create a pressurized zone in the attaching vestibule with excess conditioned make-up air.

If the intended “clean” areas must be located above or adjacent to “dirty” areas for program or site reasons, the clean areas must have their own dedicated conditioned excess make-up air. Additionally, the clean areas must have at minimum a continuous smoke sealed partition on all sides that are meticulously sealed, with appropriate fire stop/sealing materials.

The ventilation equipment that serves the school must be readily accessible, affordable to operate, and meticulously maintained, or it will not likely be working for many years after it is installed.

William A. Turner, MS, PE is president of Turner Building Science LLC, a subsidiary of the H.L. Turner Group Inc. in Concord, N.H. He has more than 25 years of experience in IAQ/HVAC evaluation and development of solutions for building system problems. Turner supervises a group of mechanical engineers, industrial hygienists and building scientists who focus on developing solutions for existing facilities and the design of high-performance buildings. You can be reach him by calling (207) 583-4571 ext. 11 or by e-mail at bturner@hlturner.com. 

Hospitals and healthcare facilities across the United States
currently follow self-regulated and some outside regulatory guidelines during construction and renovation activities. In many cases, such as for asbestos and lead, permissible exposure limits are used as guidelines for assessment and monitoring activities. These are clearly established under current standards set by state and local bodies and by the U.S. Environmental Protection Agency and the Occupational Safety and Health Administration. Control of potentially life threatening agents such as microbial and bacterial agents are not!

While it is clear that most hospitals and health care organizations intensely scrutinize these issues to reduce the incidents of hospital-acquired infections in patients, there is no current mandatory levels, standards or even published regulations. The purpose of this article is to generate some level dialogue about the development of peer-reviewed standards or concentrations for hospitals and healthcare facilities.

The Fungal Kingdom
As we are all aware, there are thousands upon thousands of different types of fungi and molds present in our little blue marble we call earth. The purpose of fungi has been well established, and we have documented that 25 percent of the earth’s biomass is from the classification, Eumycota. Without this, we would have nothing but non-decaying material everywhere and most of our resources for survival would be depleted.

Fungi and molds like any organism, wants to survive and have adapted well over the course of history. Unfortunately, their defensive mechanisms have caused documented health concerns in animals and humans throughout our existence.
Fungi have been classified in the medical setting by the level of tissue affected. This includes superficial, subcutaneous and systemic. There are three types of fungal diseases, those being allergies (inhaled fungal spores), mycotoxicoses (ingestion of fungal toxins) and “opportunistic mycoses,” which refers to serious infections in those patients with immune-compromised defense mechanisms.

Rather than listing all the various types of these diseases, they can be found in these reference materials: Jawetz, Melnick & Adelberg’s Medical Microbiology, 21st ed., Stanford, Conn.: Appleton & Lange, 1998; Pathologic Diagnosis of Fungal Infections, Chicago, Ill.: ASCP Press, 1987. Of particular concern are fungi in the categories of Aspergillus, Candida and Coccidoides, as identified in a Canada Communicable Disease Report of July 2001 and online at www.merckmedicus.com.

The Bacterial Kingdom
Similar to the fungal kingdom, there are hundreds, if not thousands, of opportunistic bacteria in our lives on a daily basis. In most cases, we are able to prevent or reduce our exposures by several methods; however, in a healthcare setting, this is critical.

Legionella spp., Nocardia asteroides, Streptococcus pneumoniae and Haemophilus influenzae are major concerns in the healthcare arena. Additional species of concern can be found in “Surveillance Standards for Antimicrobial Resistance,” published by the World Health Organization. The Centers for Disease Control have issued “Guideline for Hand Washing and Hospital Environmental Control,” a document detailing microbiological prevention of medical devices, hospital personnel, fluids and laundry, but it does not provide any acceptable levels of bacteria or fungi.

The Hospital Building
Hospitals and healthcare facilities are constructed much like any other commercial structure. They consist of a foundation, primary and secondary framing, the infrastructure (electrical, mechanical, plumbing, sewer) and finished surfaces (wall finishes, fixtures, floor coverings, appliances). Although the construction is similar, there are various microenvironments unlike one would find in normal commercial structures.

Most new construction in hospitals and healthcare providers follows the Guidelines for Design and Construction of Hospitals and Health Care Facilities published by the American Institute of Architects’ Academy of Architecture for Health. To begin, most hospitals contain significantly more plumbing for water, gases and thermal reasons than commercial tenant space. Secondly, the level of cleanliness is more of a concern considering the population within the structure. For this reason, most healthcare facilities now have a team of personnel performing an infection control risk assessment on all new construction and renovations, based on a document by the Academy for Professionals in Infection Control.

Depending on where you are in a hospital or healthcare facility, attempts are being made to maintain varying levels of cleanliness. Surgical wards, intensive care units, chemotherapy wards, organ transplant wards, sterilization rooms, dialysis units and neonatal facilities require the most stringent criteria to prevent nosocomial infections.
Recovery rooms, pharmacy, medical equipment storage and food preparation areas may have less stringent requirements, and so forth, down to loading docks, non-infectious waste storage areas and lobbies. This list is not all-inclusive but intended to provide the reader a basic understanding of the difficulty faced by infectious control personnel.
When the dynamic of renovation or construction is thrown into this already daunting task, there is a significant order of magnitude chance for problems to occur. One organization devoted to this daunting task is the Joint Commission on Accreditation of Healthcare Organizations. A visit to the commission’s Web site, www.jcaho.org, is highly recommended. Two areas of particular reference are the Key Hospital Survey Activities site and Temporary Construction Barriers.

Organism Distribution
There are several methods for distribution of these various organisms as well as the asbestos and lead components. They are air dispersion, dust transfer, medical professional to patient from contact, and random introduction by non-medical personnel. Although one might not think random introduction would be so great of a concern, it is a major source of introduction of bacteriologic and fungal materials.
Consider the case of Betsy Dart: Her 5-year-old daughter was diagnosed with leukemia, and shortly thereafter, due to her compromised immune system, she was placed into a hospital isolation room. She observed the hospital personnel rigorously wipe down the room, toys and instruments to keep her from developing infections. The room was even equipped with an air sampler to track the level of microorganisms. Although stringent efforts were taken, the girl later died from pulmonary aspergillosis.

After her daughter’s death, Dart developed a theory as to how the girl could have contracted the Aspergillus spores even though air monitoring indicated pristine conditions. As with most patients in hospitals, concerned family and friends visit and often time’s hugs, kiss and touch patients.
Family members and friends often hold small children for consolation, yet there are typically no infection prevention procedures to prevent contact with non-sterile clothing of this group. She later went on to Cornell University where she attained a master’s degree in fiber science with her thesis on the retention and re-dispersion of mold spores in fabrics (“Retention of Aspergillus Niger Spores on Textiles,” co-authored by S. Kay Obendorf, Ph.D. and published by ASTM International in 2000).

By far, the major routes of introduction are by air dispersion and dust transfer. Even though most renovations and new construction are reviewed and assessed by the infection control risk assessment, construction and renovation practices need to be closely monitored and include detailed project specifications for entry and exit procedures as well as for work performance.

Examples can be found in the documents referenced above, by the Academy for Professionals in Infection Control, in the Canada Communicable Disease Report, and in documents at www.jcaho.org.

Current Sampling Techniques For Biological Hazards
Current biological sampling methods involve air and surface sampling for both microbiological components of fungi and bacteria. However, this involves culturing of the air or surface sample, incubation and, finally, analysis. This process can prove to be time consuming, especially if sampling is performed independently or off the facility site. There are non-culturable methods for fungi; however, they are only to the genus level and cannot identify species. Both methods have some inherent flaws to them.

A new method of identification for particular species of fungi has been developed using DNA-based methods. The process is called PCR, or polymerase chain reaction. (For more information, turn to www.forensica.com/docs/mic/pcr.html.) This process allows the sample to identify both viable and non-viable fungi down to the species level in a very short period of time, rather than the 10-14 days it currently takes. Different “panels” can be created for various needs of differing industries including the health care industry. One such panel developed is the infection control panel.

The value of PCR analysis during construction and renovation is an invaluable tool to provide nearly real-time analytical data to the infection control personnel in forming opinions as to risk to the patient population. In comparing baseline results to ongoing construction results, determination can be made as to the effectiveness of the containment barrier system.

Acceptable Levels
There are many debates in the environmental industry as to what levels of fungi and bacteria are acceptable in homes and commercial buildings. Several guidelines from the American Conference of Governmental Industrial Hygienists, the American Industrial Hygiene Association and the EPA refer to recommended levels. But these are levels for the population considered being at low risk. Several states are establishing laws dealing with mold. The U.S. Congress faces the same topic on a national basis. But the fact remains that permissible exposure limits may never be established. The science hasn’t been available to confirm a dose response relationship with any degree of certainty. In light of this, what is considered acceptable for the hospital and healthcare setting?

General agreement among the environmental and industrial hygiene community is that levels of microorganisms in airborne samples should be less than outdoor ambient samples simply because most commercial building have filtered mechanical systems. Similarly, concentrations and rank order should not differ substantially. However, in a population that is more at risk, are these relative? Most IC (infectious control) personnel would readily agree they are not. What then are the acceptable levels for high-risk areas, patient rooms and general lobbies and meeting places?

There is no doubt construction and renovations in existing buildings can pose a relative risk for release of microbiological organisms. California’s health and safety codes have been revised to include the Alquist Hospital Facilities Safety Act of 1994, mandating that all acute healthcare facilities undergo complete seismic retrofit by 2008. What does this mean? All hospitals in the state that are not compliant to the recently upgraded seismic code will require substantial renovations, that will in most cases provide the potential for significant release of bacteriological material during the work.

The majority of this release will most likely come from demolition activities to access the various parts of the infrastructure. Even though advisories exist on how to perform the work, how many construction companies know how to perform this specialized operation? In our experience, even if major construction companies have the technical awareness, it doesn’t flow down to the front line workers.

The Solution?
Currently, no known dose response relationship is known for the general public at large, much less for the comprised patients in hospitals and healthcare facilities. While studies may be underway to try and establish permissible exposure limits, the science may not be there to provide answers. Regardless, healthcare facilities will need ongoing renovations and repairs that may cause substantial risk to the occupants. While general contractors may require great expertise to perform renovations in commercial and industrial facilities, hospitals should be considered a unique specialty and use of knowledgeable environmental contractors to establish and maintain regulated areas to prevent nosocomial outbreaks during the repairs.

Bruce White is the operations manager for the Los Angeles office of Forensic Analytical, an environmental consulting and analytical firm with other offices in Hayward, Calif.; Chicago, Ill.; and Paris, France. You can reach him by calling (310) 763-2374 or by e-mail at bwhite@forensica.com.