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Dear All,

Firstly, I would like to mention, that they may be limitations to the use of any intervention in regard to TB IC. I just dont want the discussion to revolve around this.

Just last week, I had a tough decision to put onto my report, that went against the installation of UVGI induct fixture in an HVAC system. The reason behind the same was a query i made on the make and technical specifications and how the maintenance would be carried out.

The limitations were there as we have a limitation of availability of units being sold in India, none or limited local makes. I am yet to learn if there are organizations that address UV installation and maintenance.

I want to understand from the group about
1. WHat are the various makes of UV fixtures available out there?
2. Are there modules and courses around training in installation and maintenance?
3. How do you manage your fixture installation and maintenance?

Looking forward to your responses.

Regards

Dyson
TB IC Consultant
Mumbai

 
Edward Nardell, MD
Replied at 12:16 AM, 26 Apr 2013

Hi Dyson,

Here is a short refresher on UVGI, responding to your questions.

First, we almost never recommend UV in HVAC (ventilation systems) for
several reasons. Disinfecting air in ventilation ducts after it leaves the
room does very little to prevent transmission in the room with an
infectious case. Although recirculation of TB has been reported, droplet
nuclei are diluted and have an opportunity to die off as they are
recirculated. Some with be exhausted to the outside in most systems. Much
more important is to disinfect air IN THE ROOM where the infectious source
is. UV can be used in fan-driven room air cleaners, but the number of
equivalent room air changes through the air cleaner is usually too low to
be very protective. Upper room UVGI has been shown to be 70-80% under real
world conditions, adding the air disinfection equivalent in our study in
South Africa of 18 air changes per hour.

Second, I do not believe that there are any locally made upper room UVGI
fixtures in India - yet. No doubt some companies will get into the
business, but since there are no standards, and there is a good chance that
locally made fixtures will not be properly tested and may be less than
optimally effective or safe. Those made in South Africa are highly
variable - so much so that there is an informal moratorium on the purchase
of UVGI fixtures in South Africa with government funds. There are two
excellent brands of fixtures made in the US, but we believe that good
fixtures can be made locally if clear specifications are provided. A
company in Russia is making inexpensive fixtures which are both safe and
effective - although very basic in design.

We have a 5-year Fogarty grant, part of which intends to:
1. develop international standard UV fixture designs that can be made in
any country and if properly done, will be safe and effective.
2. develop international planning, installation, and maintenance guidelines
3. encourage countries to stimulate local companies to provide UV fixture
commissioning and maintenance. If you put in a UV system, you budget for a
post installation commissioning report by an outside company, and annual
maintenance to be sure that the fixtures are cleaned regularly and lamps
replaced. When UVGI is widely used and companies see the potential for
profit, companies are likely to rise to the occasion and develop these
services.

I am unaware of any courses specifically teaching UV technology in depth
other than our 2 week summer course at Harvard. If there are any, perhaps
others know about them. Other, shorter courses usually discuss UVGI, but
in less detail. That was one of our rationales for the summer Harvard
course - to bring together building design, ventilation, air filtration,
UVGI, and laboratory safety in one place with lots of hands on laboratory
experience.

Finally, UVGI is the least well understood of the major technologies that
are used for TB IC. For that reason, there are many misconceptions,
including that is is ineffective, unacceptably dangerous, or hard to
maintain. UVGI can be both highly effective, safe and highly cost
effective. One of our GHDonline/TBIC moderators, Grigory Volchenkov, from
Vladamir, Russia, did a study showing that in his setting upper room UVGI
was far more cost effective than either room air filtration machines or
mechanical ventilation (HVAC) systems.

Although natural ventilation can extremely effective, especially in warm
countries, it is highly dependent (by definition) on outdoor conditions
that are inherently unreliable. Windows are often closed on cool nights or
for security. Upper room UVGI is the ideal companion technology to
complement natural ventilation.

Grigory Volchenkov, MD
Replied at 12:41 AM, 26 Apr 2013

Dear Dyson,

Several In-duct UVGI units are used in my TB facility for high risk zones exhaust air disinfection (Russian and 'Korf' (Germany)). More than 300 upper room UVGI fixtures (Russian) installed and used 24/7 in high risk rooms. Installation and maintenance carried out by trained personnel of local ventilation company and our engineer and technician.   

Regarding related training: 5 days training course for engineers and technicians on Engineering controls design, installation, commissioning and installation  for Airborne IC will be conducted in Vladimir Center of Excellence for TB Infection Control will be conducted on November 11 - 15 this year in Vladimir, Russia (with simultaneous translation in Russian and English). We just completed such course in the beginning of April.

Dr Shanta Ghatak
Replied at 1:58 AM, 26 Apr 2013

Hi Dyson
Maintenance and fixation are both taken up by a gentleman individually,
singly and singlehandedly and he does a lot of business too ! Wierd and
strange but terribly true !! The truth is we are getting by ...somehow.

S. Mehtar
Replied at 5:23 AM, 26 Apr 2013

Dear Dyson
I have just returned from a wonderful trip to Mumbai for the HISICON meeting. I did visit several establishments and found the following

1. There was little ventilation in most of the crowded areas (such as waiting areas). The reason given was that opening the windows would make the room dusty.

2. There was little or no mechanical ventilation in the state hospitals but was good in the private institutions

3. There was much confusion about UVGI at all levels of management and IPC- none of the ones I saw were appropriate
I agree with Ed- I did not find a single UVGI system in place which I could say was functioning. The two I saw were covered in dust, the level was not quite right and of course, there was no palpable ventilation!
I know Ed and I do not agree on this matter, but I do believe that if we cannot do the UVGI light system properly we really should not do it at all until we can set it up to function properly.
I will still say we emphasise what we can do well- triage of TB patients, good policies on immediate management and starting treatment, improve the ventilation and of course PPE.
I hope this helps
S


Prof Shaheen Mehtar

Buitengewoon Professor (Waarnemende Hoof:UIPC) / Extraordinary Professor (Acting Head: UIPC)

[cid:image001.png@01CE4266.931D6E40]

Eenheid vir Infeksievoorkoming en Beheer / Unit for Infection Prevention and Control
Fakulteit Geneeskunde en Gesondheidswetenskappe /
Faculty of Medicine and Health Sciences
Universiteit Stellenbosch University
Posbus / PO Box 19063; Francie van Zijl Rylaan / Drive
TYGERBERG 7505
Suid-Afrika / South Africa
Tel: +27 21 938-5054; Faks / fax: +27 21 931-5065
e-pos / e-mail: <mailto:>

Edward Nardell, MD
Replied at 7:01 AM, 26 Apr 2013

Hi Shaheen,

I think we have been debating long enough that we are beginning to agree!!
I agree that if UVGI cannot be done well, it should not be used at all.
Our goal to to make it possible for it to be done well in India, Africa,
and everywhere else. The same cautions should be said of mechanical
ventilation, respirator use, and even natural ventilation, although the
cost of the latter is usually less. Assuring that a building is properly
ventilated by natural airflow is often not trivial, and can be costly if
major renovations are required, but is not dangerous except in false
assurance if not really working. And you know I agree that the single most
important TB infection control intervention is rapid detection, rapid
diagnosis, and prompt institution of EFFECTIVE treatment based on a DST.

S. Mehtar
Replied at 7:26 AM, 26 Apr 2013

Yes. Getting there slowly!! I do still worry about the UVGI application in LMI countries- above all else!!
S

Prof Shaheen Mehtar

Buitengewoon Professor (Waarnemende Hoof:UIPC) / Extraordinary Professor (Acting Head: UIPC)

[cid:image001.png@01CE4281.34826BE0]

Eenheid vir Infeksievoorkoming en Beheer / Unit for Infection Prevention and Control
Fakulteit Geneeskunde en Gesondheidswetenskappe /
Faculty of Medicine and Health Sciences
Universiteit Stellenbosch University
Posbus / PO Box 19063; Francie van Zijl Rylaan / Drive
TYGERBERG 7505
Suid-Afrika / South Africa
Tel: +27 21 938-5054; Faks / fax: +27 21 931-5065
e-pos / e-mail: <mailto:>

Kendrick Lau
Replied at 9:12 AM, 26 Apr 2013

Hi Dr. Nardell,

Could you please send me info regarding the summer course at Harvard? I will be back stateside this summer, but depending on dates, may or may not be able to attend. Is there a softcopy of the syllabus available? I haven't been able to find a reliable source for UVGI in our immediate area (West Africa), but would be interesting in looking at US sources as well as investigating further options for a sustainable, maintainable system in a resource-limited, mission hospital context.

Thanks,

Kendrick Lau

Robert Spiteri
Replied at 10:35 AM, 26 Apr 2013

Hi,



Ultra Violet into the air-conditioning system can be effective in
controlling airborne pathogens. The biggest problem with air cons is that if
UVGI is not installed correctly it can be the cause of spreading TB. It
would be very nice to obtain a copy of the results of tests that were
carried out in South Africa. As an aerobiological engineer I have had
enormous success in controlling airborne pathogens through the aircon
systems. This my reason why I would like to see why the tests in South
Africa failed.

There are 2 forms of sanitation in air-conditioning.

. One is surface disinfection of the coils

. Air sanitation - the passing of air over UV light at the correct
speed for its intensity to obtain maximum sanitation so that the pathogen
does not recover in the dark time.

The International Association of Ultra Violet have guidelines for the
installation of UV into the air-conditioning ducts and also have data on
types of lamp and the effects of cooling the lamp with performance figures
at different temperatures.

South Africa produced a number of UVGI fixtures, some have proved to be more
effective and reliable than others. Should you require more information
contact me directly.

Edward Nardell, MD
Replied at 11:18 AM, 26 Apr 2013

Dear Kendrick,

Here is the link to the Harvard Course:
https://ecpe.sph.harvard.edu/programs.cfm?CSID=AIR0000. You can also Google
"Harvard Building Design and Engineering Approaches to Airborne Infection
Control"

We are actually targeting W. Africa and other French-speaking regions this
year with full simultaneous translation. However, it is getting late,
especially for scholarship help, which is limited. We use nearby college
dormitories (AC and WiFi) to keep housing costs down, although there are
also local hotels. Please submit an application as soon as possible if you
would like to attend this year. We get more applications than there are
spots, and priority is given to individuals who have the potential for
regional impact. That said, the class is usually quite diverse in terms of
background, training, and experience.

Edward Nardell, MD
Replied at 12:42 PM, 26 Apr 2013

Mr. Spiteri's response contains many misleading issues that require a
moderator's response.

1. The statement that UV in ducts can be effective in controlling airborne
pathogens. I would ask WHERE IS THE DATA? More specifically, where is the
data for TB? It is easy to show that UV will kill test organisms,
including mycobacteria, in ventilation ducts, but that is not the issue.
The issue is how likely UV in ducts is to control airborne infection for
occupants of rooms or buildings. For example, if I have infectious TB and
am coughing and there are 3 other susceptible people in the SAME room, how
much person to person transmission is prevented IN THAT ROOM if the air is
disinfected AFTER it leaves the room? As I mentioned, there some potential
for the re-circulation of TB organisms, as has occasionally been
documented. The most dramatic example was the SS. Byrd naval vessel, where
TB infection was spread through the confines of a ship, aided by the
ventilation system. However, upper room UVGI can reduce transmission IN THE
SAME ROOM where the source is located. It is always better to contain
airborne hazards close to the source. But, upper room UV ALSO PREVENTS
RE-CIRCULATION of TB in ventilated buildings since rooms are an important
part of the ventilation circuit. You get both local air disinfection and
disinfection of recirculated air with the upper room approach.

Mr. Spiteri says: "As an aerobiological engineer I have had enormous
success in controlling airborne pathogens through the aircon systems. This
my reason why I would like to see why the tests in South Africa failed."

I DID NOT suggest that there were ANY studies that showed that UV in ducts
had failed in South Africa. I am not aware of ANY studies of UV in ducts
to prevent TB transmission to people in buildings anywhere, not just South
Africa. When he says that "I have had enormous success in controlling
airborne pathogens through the aircon systems" what exactly does that mean?
What success? Surely he has not done epidemiological studies showing less
TB transmission in hospitals or clinics using UVGI in their aircon systems.
Such studies would be extremely difficult. Compared to what? AGAIN,
killing aerosolized test organisms in ducts does not mean stopping person
to person transmission in rooms. Such data are commonly shown by
manufacturers of duct UV systems or room air cleaners to sell their
products.

2. The hospital tests of UPPER ROOM UVGI in South Africa (soon to be
published) were highly successful, as were similar hospital tests of upper
room UVGI in Peru (published, Escombe, et al), finding 70-80% efficacy
preventing TB transmission under real hospital conditions in two very
different settings with very different UVGI fixtures and air mixing fans.
Both UVGI installations were safe and effective, putting to rest any
question of poor efficacy for upper room UVGI. Our study in South Africa
added the air disinfecting equivalent of 18 room air changes per hour (ACH)
to the existing 6 ACH, for a total of 24 ACH, most due to the UVGI. Had
there been a recirculating ventilation system (it is a single pass system)
and used UV in the duct work, the maximum effect would still only be 6 ACH
- the ventilation rate. Recirculated air would all be the TB-free
equivalent of outdoor air, but the dilution effect in the room would be
limited by the 6 ACH HVAC setting. We achieved 4 times that protection
using upper room UVGI with a paddle fan plus the 6 mechanical ACH
ventilation.

3) South Africa does produce a number of UVGI fixtures. At the moment,
however, there are no international standards for design or performance.
We hope to correct that, but in the meantime, as mentioned, the South
African Coucil for Scientific and Industrial Research (CSIR) has imposed an
informal moratorium on the use of upper room UVGI with government funding.
This follows the flooding of the market with many poor fixtures.
International guidelines on UVGI are badly needed, including fixture
specifications, performance, placement, commissioning, and maintenance.
Until those parts are in place, the use of UVGI for air disinfection,
while potentially extremely effective, remains an inexact practice. South
Africa has published UVGI guidelines which are still adequate, but they do
not specify fixture performance or commissioning.

I am not suggesting that upper room UVGI not be used. It is not rocket
science. With some detailed on-line research, fixtures with good
performance specs can be purchased, properly installed, commissioned, and
maintained, with an excellent chance that the installation will be both
safe and effective. There are a growing number of consultants who have been
trained in the use of natural ventilation, mechanical ventilation, and UVGI
at the Harvard, Vladamir, South African, and assorted other courses where
unbiased information has been presented.

This is an open forum and anyone is welcome to post. However, one of the
roles of moderators is to be sure that commercial interests, that is, paid
consultants and manufacturers, do not use the site to promote their
products or services, with unsupported claims such as, "enormous success in
controlling airborne infection". We need consultants and we need the
involvement of industry, but policy needs to be based on independent
assessments by responsible public agencies, such as the CSIR in South
Africa, based on science.

Peta de Jager
Replied at 2:08 AM, 29 Apr 2013

Dear community. A minor correction to Ed's response above. The South African National Department of Health (NDoH) imposed the moratorium on UVGI based on multi-agency report prepared for the Surgeon General which identified several key failures in its application in SA. The CSIR may not have the necessary mandate/authority to make such a moratorium binding, where NDoH does. We are in support of the moratorium and with partners (NIOH, UP and MRC) are working with CDC funding to introduce some of the necessary checks and balances, to support human capital development and training and so on. We do, however, still have a long way to go...

Robert Spiteri
Replied at 2:57 AM, 29 Apr 2013

Thanks for update

Dries Meyer
Replied at 4:37 AM, 29 Apr 2013

I agree with Peta that here is still a long way to go, actually more
than a long way.

I was involved in UVGI for more than 14 years and no positive forward
step was taken by the National Department of Health. The final straw for
me was when I spoke to a senior person at the Department and was told
that they have no evidence to prove that the "TB bacteria is killed when
it sticks to the UV-C radiation".

I decided that enough was enough and stopped all my involvement in UVGI
work.

S. Mehtar
Replied at 6:17 AM, 29 Apr 2013

Thanks Peta
That is really good to know- and get some sense out of the system
S

Prof Shaheen Mehtar

Buitengewoon Professor (Waarnemende Hoof: UIPC) / Extraordinary Professor (Acting Head: UIPC)

[cid:image001.png@01CE44D3.7385A650]

Eenheid vir Infeksievoorkoming en Beheer / Unit for Infection Prevention and Control
Fakulteit Geneeskunde en Gesondheidswetenskappe /
Faculty of Medicine and Health Sciences
Universiteit Stellenbosch University
Posbus / PO Box 19063; Francie van Zijl Rylaan / Drive
TYGERBERG 7505
Suid-Afrika / South Africa
Tel: +27 21 938-5054; Faks / fax: +27 21 931-5065
e-pos / e-mail: <mailto:>
Visit our website at www.sun.ac.za/uipc<http://www.sun.ac.za/uipc>
5th ICAN/ IPNET-K conference, 6-8th Nov, 2013, Mombasa, Kenya. www.ICNetwork.co.za

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