TB Infection Control

I think this discussion is remarkable and most interesting but is becoming repetitive.
I would like to see some data, worldwide if possible, where UVGI is installed in various healthcare clinics and compare this data between the HI and LMI countries. For instance, does Cooks County Hospital (Chicago) which is a state hospital have UVGI in the admission, OPD and wards? Does Boston General or Tufts have UVGI installed anywhere, everywhere? Perhaps Ed can enlighten us.
Should we have UVGI at the Princess Grace Hospital in the UK where a large number of private patients from abroad are seen? Should the NHS hospitals in high population risk areas have UVGI installed?
Do the hospitals in The Netherlands, Belgium and other European Hospitals have UVGI in the hospitals.
I think we should open this debate to another level. What prevalence of TB in a community or country will warrant the use of UVGI- given all the issues currently discussed here? Very specific guidelines of how, when and where would be useful. And, of course we need to access the most recent data on the Airborne Lab from Joburg!!
What do the group think?
Regards
S

Prof Shaheen Mehtar
MBBS, FRC Path ...

I think this discussion is remarkable and most interesting but is becoming repetitive.
I would like to see some data, worldwide if possible, where UVGI is installed in various healthcare clinics and compare this data between the HI and LMI countries. For instance, does Cooks County Hospital (Chicago) which is a state hospital have UVGI in the admission, OPD and wards? Does Boston General or Tufts have UVGI installed anywhere, everywhere? Perhaps Ed can enlighten us.
Should we have UVGI at the Princess Grace Hospital in the UK where a large number of private patients from abroad are seen? Should the NHS hospitals in high population risk areas have UVGI installed?
Do the hospitals in The Netherlands, Belgium and other European Hospitals have UVGI in the hospitals.
I think we should open this debate to another level. What prevalence of TB in a community or country will warrant the use of UVGI- given all the issues currently discussed here? Very specific guidelines of how, when and where would be useful. And, of course we need to access the most recent data on the Airborne Lab from Joburg!!
What do the group think?
Regards
S

Prof Shaheen Mehtar
MBBS, FRC Path (UK), FCPath (Micro) (SA), MD (Lon)
Head of Academic Unit for Infection Prevention and Control
Tygerberg Hospital & Stellenbosch Uni
PO Box 19063,
Tygerberg 7505, Cape Town
Tel: +27 21 938 5051
Fax: + 27 21 938 5065
Mobile: +27 82 852 3697
http://www.sun.ac.za/uipc
Infection Prevention and Control Africa Network
Visit website: www.ipcan.co.za. for information on
3rd IPCAN Conference, Namibia- 29th Oct-3rd Nov 2011

Dear Thea,
Dear Dr. Dries,

It seems this discussion wanders a bit away from the actual problem, UVGI. I think it is worthwhile to start a discussion on consulting teams and how to appoint them in a separate forum.
I agree with Thea on the ventilation and I'm aware of these problems too. I'll promise you, I'll start a discussion on this topic soon.
Just coming back to the consultants, most of the improvements / problems I have been referring to are the ones where no Architect or Consultant is involved. The mean reasons being:
• The project is often so small that a consultant team is not needed, or that is what the client thinks.
• The consulting team is not interested in such a small job.
• There is no money available to pay for consultants as donor only allows for purchasing equipment.
• Wrong people might take decision on what will be ordered. Very often in case of UVGI fittings, a Hospital or IC Committee has for example US$ 10,000. - from donor for fittings, the whole amount is used to order these fittings. Based on some assumptions these fittings are distributed over the hospitals and installed by the ...

Dear Thea,
Dear Dr. Dries,

It seems this discussion wanders a bit away from the actual problem, UVGI. I think it is worthwhile to start a discussion on consulting teams and how to appoint them in a separate forum.
I agree with Thea on the ventilation and I'm aware of these problems too. I'll promise you, I'll start a discussion on this topic soon.
Just coming back to the consultants, most of the improvements / problems I have been referring to are the ones where no Architect or Consultant is involved. The mean reasons being:
• The project is often so small that a consultant team is not needed, or that is what the client thinks.
• The consulting team is not interested in such a small job.
• There is no money available to pay for consultants as donor only allows for purchasing equipment.
• Wrong people might take decision on what will be ordered. Very often in case of UVGI fittings, a Hospital or IC Committee has for example US$ 10,000. - from donor for fittings, the whole amount is used to order these fittings. Based on some assumptions these fittings are distributed over the hospitals and installed by the local electrician. (WRONG WAY)
I also agree that consulting teams are costly, but they don't always have to come from other countries. Most of the local engineers know there work rather well. Very often, the lack of a brief or the right information is the problem. On top of that, donors seldom budget for consulting fees. If local engineer can build shopping malls, hotels and offices with mechanical ventilation and air-conditioning, for sure they can design basic ventilation for hospitals. They just should be involved, paid and get the right information.
Regarding the financing I can only talk out of own experience. As most of the Ministry of Health Budgets are planed far upfront and are much stretched, it is difficult to find additional funding for partly funded donor projects. Most donor-funded projects only allow for the purchase of goods or goods are donated. Seldom there is money available to appoint a consulting team for proper installation or even to do maintenance in the future. The receiver on the other side is seldom aware of the fact that when they receive a US$ 1.000.000,- renovation / new building or goods, they end up with yearly additional costs of US$ 100.000,- ( 10% annually of building costs) to maintain this building or these goods. Hence the BSC without maintenance and mechanical ventilations in hospitals not working.
A long-term, commitment from the donor might be a solution to the problem.

Hans

Dear Dr. S. Mehtar

A real good point. I fully agree. Do we really need UVGI in all facilities? Do we really have to run home and buy 100 UVGI fittings and have them randomly placed in our facility? I guess this is the real point.

Dear Hans and Dr. Mehtar,

I would not agree with your scepticism regarding UVGI: from my pesonal experience upper room UVGI is low cost, minimal maintenance and effective enough intervention which should be a choice for high risk and limited resource settings.

VERY important: to choose appropriate fixtures, professionally install and commission, and clean correctly and regularly (weekly - monthly - quarterly, depending of dust content in the room air), monitor perfomance twice a year. UV-C radiometer with 254 nm probe is absolutely needed for installation, commissioning and  monitoring, but it is enough to have just one device for the region or small country.

Again, administrative controls are fundamental for risk reduction, but still we need affordable and feasile environmental controls and respiratory protection in some highest risk settings where only administratives alone can't reduce the risk to zero.

Regards,

Dr. Grigory V. Volchenkov


Head Doctor
Vladimir Oblast TB Dispansery


Sudogodskoe shosse, 63
Vladimir 600023 RUSSIA


phone/fax work: +7(4922)323265
mobile +7 920 625 3227; +7 919 018 9226

Dear Gregory
I agree with you but I have to consider the circumstances in LMI countries. I would be most interested in the reduction in HAI TB cases you have recorded before and after the installation of UVGI- I know it is not perhaps the best way to evaluate the system but I know that the MRC in South Africa is working hard on getting some answers for LMI countries- your experience in this regard is invaluable.
Regards
Shaheen

Prof Shaheen Mehtar
MBBS, FRC Path (UK), FCPath (Micro) (SA), MD (Lon)
Head of Academic Unit for Infection Prevention and Control
Tygerberg Hospital & Stellenbosch Uni
PO Box 19063,
Tygerberg 7505, Cape Town
Tel: +27 21 938 5051
Fax: + 27 21 938 5065
Mobile: +27 82 852 3697
http://www.sun.ac.za/uipc
Infection Prevention and Control Africa Network
Visit website: www.ipcan.co.za. for information on
3rd IPCAN Conference, Namibia- 29th Oct-3rd Nov 2011

Dear Shaheen,

Average (for 1993 - 2002) notification rate of occupational TB among staff in my dispansery before we started intensive TBIC project was 1080 per 100K (risk 22 times higher than for resident population). Average for first 5 years after the beginning - 160 per 100K.  We had no new TB cases among staff in 2008 - 2010. I dont't say the risk now is zero, but we really see substantial reduction.

Sure it is not upper room UVGI (started in 2004 - 2005) only, the TB IC interventions are complex (various administrative controls, mechanical ventilation, upper room UVGI, BSCs, and respirators in designated high risk zones) and it is impossible to say what was the impact of any particular intervention. But  again EVERYTHING is not perfect so I believe it worth to rely on various interventions to get maximal possible effect.

Regards,

Dr. Grigory V. Volchenkov


Head Doctor
Vladimir Oblast TB Dispansery


Sudogodskoe shosse, 63
Vladimir 600023 RUSSIA


phone/fax work: +7(4922)323265
mobile +7 920 625 3227; +7 919 018 9226

Dear Gregory

Sorry for the miss understanding. I'm not against UVGI at all. I think it is a helpful source to reduce infections and clean air as long as it is used in the right way.

My problem is, that currently the public(Hospitals) see it as the "one and only" solution and very often the UVGI fittings are installed /ordered without proper knowledge. Hence, the rather large amount of problematic fixtures and wrong installations I encounter on my assessments.
This might mainly have to do with, EDUCATION, EDUCATION and EDUCATION. I think this is the real problem to address.
Hans

Dear Gregory,

I agree that it will be difficult to determine the exact impact of UVGI
in an existing hospital or clinic, because of the complexity of the
different interventions involved. I think the only way to make an
efficacy estimate would be to compare records of infection before a
specific intervention was installed, with records after installation.

Regards,
Dries Meyer (Freelance Engineering Services Consultant)

Dear Gregory
Yours is convincing evidence indeed! As an IPC practitioner I would be very happy with such results. In your situation it is clear that UVGI has augmented your IPC practices and has supported the containment of TB well. Well done!!!
Shaheen

Prof Shaheen Mehtar
MBBS, FRC Path (UK), FCPath (Micro) (SA), MD (Lon)
Head of Academic Unit for Infection Prevention and Control
Tygerberg Hospital &Fac of Health Sciences, Stellenbosch Uni
PO Box 19063,
Tygerberg 7505, Cape Town
Tel: +27 21 938 5051
Fax: + 27 21 938 5065
Mobile: +27 82 852 3697
http://www.sun.ac.za/uipc
Visit the IPCAN website on
http://www.ipcan.co.za

Dear all,
it is very difficult to give an “absolute answer” about UVGI installations.

It is important to note that UVGI installation is much cheaper (more sustainable) then, for example, a mechanical ventilation system. Both in terms of installation as well as in terms of maintenance. UVGI installation is a very good solution in particular for cold countries where the fact of providing ACH means as well to continuously heat the cold air coming from the environment, or to filter the air before recirculation.

On the other hand, this is true if the considered location is at least a middle income country, if, for example, the considered rural clinic already has electricity... some years ago a study has been conducted (presented at the 2009 TSRU) and a natural ventilation system (of course with no air recirculation) has been compared to a UVGI installation in a low income cold country.
Considering to improve the building envelope behavior with some passive heating systems implementation and the additional costs due to increased heating demand for the natural ventilation system; considering the installation of electricity and all needed spare parts for the UVGI system. Considering both set ups on a 5 years-base study, the ...

Dear all,
it is very difficult to give an “absolute answer” about UVGI installations.

It is important to note that UVGI installation is much cheaper (more sustainable) then, for example, a mechanical ventilation system. Both in terms of installation as well as in terms of maintenance. UVGI installation is a very good solution in particular for cold countries where the fact of providing ACH means as well to continuously heat the cold air coming from the environment, or to filter the air before recirculation.

On the other hand, this is true if the considered location is at least a middle income country, if, for example, the considered rural clinic already has electricity... some years ago a study has been conducted (presented at the 2009 TSRU) and a natural ventilation system (of course with no air recirculation) has been compared to a UVGI installation in a low income cold country.
Considering to improve the building envelope behavior with some passive heating systems implementation and the additional costs due to increased heating demand for the natural ventilation system; considering the installation of electricity and all needed spare parts for the UVGI system. Considering both set ups on a 5 years-base study, the result showed a clear economical convenience with the natural ventilation which arrived to be more then 10 times cheaper then the UVGI system. It is important to remind that this kind of results depends (a lot) from the specific climatic conditions of the considered location. In addition I would like to point out as well that if UVGI is clearly designable; natural ventilation, even if well designed, has always a complement of “unpredictability” given by the external weather conditions. Unfortunately the mentioned study stayed on a pure study phase and had never been conducted with “real” data. (no funds for the implementation of a proper natural ventilation + passive solar system design have been found) therefore no “real” evidence is available (to my knowledge).

All this to say that UVGI, as all interventions, needs to be evaluated case by case.

Best regards
Thea Zuccotti, Architect

Specialist Consultant in
Health Structure Design and
Infection Control Strategies
TBTEAM Roster Expert
http://www.stoptb.org/countries/tbteam/

Dear Thea:
Could you clarify if the comparative study you mention is specific to Upper Room UVGI?

My apologies to this group, but when the members refer to UVGI is it assumed that it refers to Upper Room UVGI and not to say UVGI's installed in ducts etc.?

Thanks
Sriram Krishnan
UCT

Dear Sriram,

thank you for asking, yes: the study was conducted with Upper Room UVGI installations.


regards/Thea

Dear All,

I propose that we use the abbreviations UPP-UVGI for upper volume UVGI
and ID-UVGI for in duct UVGI.

Regards,
Dries Meyer. (Independent Engineering Services Consultant.)

In my view we have too many acronyms to deal with as it is. "Upper room UVGI" is short enough as is "In-duct UVGI" - with no possibility of confusion for lack of knowing what the acronyms mean.

Hello all, possibly here is more proof of efficacy ...
http://www.infectioncontroltoday.com/news/2011/04/hospital-study-demonstrates...