Contents National TB infection control seminar 2015 CSIR, Pretoria Jako Nice, Architectural researcher CSIR GAZZETED TB SERVICES GUIDELINES Iuss HEALTH FACILITY GUIDES TB SERVICES August 11th, 2015, CSIR, Pretoria Acknowledgement of Tobias van Reenen & Peta De Jager

Built environment _people of interest TECHNICAL TEAM HEALTH PLANNER DESIGNERS ARCHITECT LANDSCAPE INTERIOR ENGINEERS ELECTRICAL CIVIL MECHANICAL STRUCTURAL ACOUSTIC FIRE TRAFFIC GEO-TECHNICAL CONSULTANT GREEN CONSULTANT HERITAGE CONSULTANT SECURITY CONSULTANT LIGHTING DESIGNER CLERK OF WORKS CONTRACTOR SUB – CONTRACTORS SPECIALIST CONTRACTORS SUPPLIERS MANAGEMENT TEAM CLIENT CLIENT REPRESENTATIVES BOARD REPRESENTATIVES CLIENT TREASURER CLIENT USER (Dr, Nurse) PROJECT MANAGER QUANTITY SURVEYOR STATUTORY BOARDS LOCAL MUNICIPALITY APPROVALS BUILDING INSPECTORS DOH NORMS AND STANDARDS APPROVAL PROCESS COUNCIL APPROVALS CLIENT SERVICE CONTRACTS IN PLACE NATIONAL CONTRACTS COMPANY DESIGN GUIDES OTHER: SABS/SANS CERTIFICATIONS NEW ROLEPLAYERS OR PLAYERS WITH INTEREST Infection control specialist, epidemiologist, microbiologist, building scientists

IUSS background Weak health infrastructure law: SAHNorms (public sector) repealed R158 (private sector) – outdated R187 (WC) and draft regulations (GP, FS) Built environment professionals have no healthcare specialisation, and vice versa Initial capital cost: maintenance: service delivery 1 : 5 : 25 New national guidelines commissioned by the National Department of Health

IUSS background_Norms and Standards objectives “Development of a sustainable set of universally adopted national norms, standards, guidelines , tools and benchmarks for all levels of health care facilities to inform and guide work related to all stages of the health infrastructure lifecycle from strategic planning through to operation and disposal.”

IUSS background_ application These IUSS voluntary standard/ guidance documents have been prepared as national Guidelines, Norms and Standards by the National Department of Health for the benefit of all South Africans. They are for use by those involved in the procurement, design, management and commissioning of public healthcare infrastructure. It may also be useful information and reference to private sector healthcare providers. . The development process adopted by the IUSS team was to consolidate information from a range of sources including local and international literature, expert opinion, practice and expert group workshop/s into a first level discussion status document. This was then released for public comment through the project website, as well as national and provincial channels.

IUSS bacground_ application continued At all development stages documents may go through various drafts and will be assigned a version number and date. The National Department of Health will establish a Health Infrastructure Norms Advisory Committee, which will be responsible for the periodic review and formal update of documents and tools. Documents and tools should therefore always be retrieved from the website repository www.iussonline.co.za or Department web portal (forthcoming) to ensure that the latest version is being used. The guidelines are for public reference information and for application by Provincial Departments of Health in the planning and implementation of public sector health facilities. The approved guidelines will be applicable to the planning, design and implementation of all new public-sector building projects (including additions and alterations to existing facilities). Any deviations from the voluntary standards are to be motivated during the Infrastructure Delivery Management Systems (IDMS) gateway approval process. The guidelines should not be seen as necessitating the alteration and upgrading of any existing healthcare facilities.

Healthcare environment/ crosscutting issues Procurement and operation 10/3/2017 Clinical services Adult Inpatient Services Laboratories Mental Health Adult Critical Care Emergency Centres Maternity Care Facilities Oncology Outpatient Services Paediatric and Neonatal Facilities Pharmacy Primary Health Care Diagnostic Radiology Adult Physical Rehabilitation Adult Post-acute Services Facilities for Surgical Procedures TB Services Support services Admin & Related General Hospital Support Catering Services Linen and Laundry Hospital Mortuary Services Nursing Education Institutions Health Facility Residential Central Sterilising Services Department Training and Resource Centre Infrastructure Design for Waste Management Healthcare environment/ crosscutting issues Generic Room Data Security Engineering design principles Environment and Sustainability Materials and Finishes Future healthcare environments Healthcare Technology Inclusive environments Infection prevention & control Information Technology & Infrastructure Procurement and operation Integrated infrastructure planning Project planning and briefing Space guidelines Cost Guidelines Innovative Building Technologies Commissioning Maintenance Decommissioning Capacity development X X X X X X LEGEND Gazetted Guidelines Toolkits Position papers Regulations X X Regulations Regulations

IUSS TB SERVICES_HEALTH FACILITY GUIDES Part A Policy and service context Part B Understanding Transmission to manage risk Part C Planning and design principles Part D Operational narrative and user room requirements Part E Case studies Annexure – Sputum booth etc.

PART A_Policy and service context (1) Infection Prevention and Control Legislation Building legislation Infection prevention and control and TB management policy and guidelines South African building practice policy and guidelines International design guidance

PART A_Policy and service context (2) Burden of disease Disease treatment Service centres (refer to related IUSS guides) HCW risk TB management (service model)

PART B_Understanding Transmission to manage risk Transmission of TB – overview Disease status – at date of the document (consider as a live document) Manifestations of TB (d/sup TB, pre MDR TB, MDR TB, pre XDR TB, XDR TB, Paeds) Origin of airborne infection Infection prevention and control hierarchy Administration IPC measures Environmental IPC measures Dilution systems Ventilation systems (natural, mixed mode, mechanical) Disinfection systems Personal Protection measures

Ventilation design philosophy PART B Hierarchy of Design Solutions Ventilation design philosophy Fully mechanical ventilation Hybrid systems with climatic adaptability Fully passive ventilation Occupants/equipment NOT ADAPTABLE or tolerant of indoor conditions Occupants/equipment ADAPTABLE or tolerant of indoor conditions Occupied areas

PART B ENVIRONMENTAL CONTROLS Ventilation concepts Natural ventilation Mechanical ventilation Mixed mode ventilation DISINFECTION concepts ULTRAVIOLET GERMICIDAL IRRADIATION (UVGI) Upper room UVGI Whole room UVGI In-duct UVGI Filtration units/ room air cleaners UVGI Disinfection of Room Air: An Evidence Based Guideline for Design, Implementation and Maintenance

PART B Ventilation – What is it? Movement of air “Pushing” and/ or “pulling” of particles and vapours Preferably in a controlled manner Ventilation is more effective if: Air flows from “clean” to “contaminated” (directional airflow) There is good air-mixing (no stagnation or short circuiting) There are fewer obstructions and encumbrances WHO recommends the use of ventilation to manage airborne infection risk: the better ventilated the area, the lower risk of transmission of TB and other airborne infections

Climate impacts on building use PART B_ expounded Climate impacts on building use CSIR 2010 map. Based on 60 000 1 km x 1 km cells. 16

(Stratified Distribution) PART B PRINCIPLES OF VENTILATION Displacement: (Stratified Distribution)

(Mixed Air Distribution) PART B_ PRINCIPLES OF VENTILATION Dilution: (Mixed Air Distribution)

PART B_Natural ventilation Natural (or passive) ventilation Mechanisms: • Buoyancy (stack effect; thermal) • Pressure driven (wind driven; differential pressure) Applications: • Supply of outdoor air • Removal of pollutants • Cooling Concerns: • Weather-dependence: wind, temperature, humidity • Patient comfort • Safety and security • Outdoor air quality • Noise • Mosquitoes Building design: • Position, functionality and size of apertures • Building materials (trombe walls, white roofs) Measurement and verification

Environmental controls – natural ventilation PART B_ expounded Natural ventilation – dilution ventilation Calculating ACH is the simplest way to assess ventilation ACH = Volume of air moved in one hour One ACH means that the volume of air in the room is replaced in one hour However recently we’re interested in relating these back to occupancy levels i.e. litres/ second/ person Environmental controls – natural ventilation

Airborne Contamination Control PART B_Natural ventilation Airborne Contamination Control Each doubling of the airflow (m³/s or ACH) reduces airborne infection risk by half

PART B Guideline For natural ventilation, a minimum hourly averaged ventilation rate of 160 L/s/patient for airborne precaution rooms (with a minimum of 80 L/s/patient). 160 l/s 80 l/s • When natural ventilation alone cannot satisfy the requirements, mechanically assisted natural ventilation system should be used. • Overall airflow should bring the air from the agent sources to areas where there is sufficient dilution, and preferably to the outdoors.

PART B Natural ventilation – factoring in occupancy rates CDC and WHO have begun relating ventilation rates to occupancy Room Volume 24.0 m³ Ceiling ht 2.7 m Floor area 8.9 m² LxB 3.0 Occupancy 2 people Fresh air per person 160.0 60 40 l/s/p Ventilation rate 320.0 120.0 80.0 l/s 1152.0 432.0 288.0 m³/h Air change rate 48.0 18.0 12.0 ACH

Environmental controls – natural ventilation PART B Natural ventilation – factors in efficacy Environmental controls – natural ventilation

PART B_Mechanical ventilation HVAC:- Heating Ventilation and Air Conditioning Ventilation:- The process of supplying air to or removing air from a space for the purpose of selectively controlling: -air contaminant levels (purity), -humidity - & sometimes temperature Air-Conditioning:- A process for controlling the: -Temperature, -Humidity and -Sometimes the Purity of the air.

Terminology & Definitions PART B_Mechanical ventilation Terminology & Definitions Ventilation rate:- Air changes per hour (AC/h) (Air Change Rate) Supply Air:- Air forced into the space (m³/s) In/Exfiltration:- Air leaking into or out of a space (m³/s) Extract Air:- Air drawn from a space Exhaust Air:- Air exhausted to outside the HVAC system

PART B_Mechanical ventilation WHY RECIRCULATE? Consider a conditioned space which is maintained at 22°C: Cooling plant energy cost is reduced by between 80% and 95% Lower energy and operating cost at the cooling plant. Smaller cooling plant and lower capital cost Disadvantage: More difficult to maintain indoor air quality

PART B_Disinfection systems

PART B_Disinfection systems Ultraviolet (UV) light is invisible to the human eye UV is generated naturally by sunlight in three bands UVA which can penetrate the atmosphere and window glass UV-A, the long wave UV, as known as black light, is responsible for skin tanning and applied in medicine to treat certain skin disorders. It is the most part of UV light that reaches the Earth's surface. UVB which can penetrate the atmosphere (but not glass) UV-B, a small, but dangerous part of sunlight, is mostly absorbed by the Earth's atmospheric ozone layer. Prolonged exposure could result in unhealthy effects on the skin and eyes. UVC which is filtered out by the ozone layer UV-C, the short wave UV, which includes optimal germicidal ultraviolet at 253.7 nanometres (nm) wavelength, is used for air, surface and water disinfection. However, exposure to UV-C causes skin redness and eye irritation and, therefore, this should be any precaution sign when UV-C light is applied in occupied areas. UV can be artificially generated and this is most commonly done by modifying fluorescent strip (Mercury arc lamps) UV light does not penetrate human tissue (skin) deeply. However there are indirect effects throughout the body In controlled scientific studies UV lights have been demonstrated to be effective against mycobacterium Tuberculosis and other pathogens The South African National Department of Health declared a moratorium on the purchase and installation of UVGI in public health facilities in 2011.

PART B_Disinfection systems SATS 1706: UVGI Luminaires – Safety and performance requirements UVGI Disinfection of Room Air: an evidence based guideline for design, implementation and maintenance The 1st proposed standard under development, released for comment and circulation at a recent UVGI summit hosted by the CSIR.

PART C_Planning and design principles (1) Specialised TB treatment design requirements a safe, secure and functional environment for patients and staff; optimal accommodation and support for long term patient stay; low capital and on-going operating costs (service, staffing and maintenance); an environmentally appropriate design solution; and a fully accessible, inclusive environment. Patient profile Patient – centred care Staff patient ratios Supporting the caregiver Site appraisal Additional project studies, approval and requirements

PART C_Planning and design principles (2) Patient – centred care Safety Isolation Infection prevention and control Slips, trips and falls Alarms and fire alarms UV exposure risk Security Inclusive design Holistic care Balanced service provision Healing environments Occupant comfort

PART C AIRBORNE CONTAMINATION CONTROL CONCEPTS Physical Segregation:- Isolation & Containment Aerodynamic Effects:- Displacement - Laminar Flow (operating theatres etc.) Dilution - Contaminants generated in the space are continuously diluted by the portion of fresh/treated air supplied into the space. Nt/No =e-kt Where: N = initial concentration Nt = concentration at time t k = rate of removal in ACH

PART C Design approach • Design out • Building typology: – single load, cross ventilation • Ensure and verify consistency under all ventilation regimes – Flow of infectious agents directly out of building – Avoid flow toward other patients, especially susceptibles • People-proof your design and ensure management plans Design out (after Dr Nardell)

PART C_Thermal comfort Thermal Comfort concerns how people respond to: Heat Transfer from their bodies and Air Quality CIBSE KS06

PART C THERMAL COMFORT THERMAL COMFORT Building Design and Engineering Approaches to Infection Control : 2013 CIBSE KS06

PART C Factors that influence how we perceive thermal comfort: THERMAL COMFORT Air Temperature Relative Humidity Mean Radiant Temperature Air movement (Velocity) Clothing Level Activity Level Social & Psychological Factors The number of factors that influence go way beyond dress and temperature

PART C_Staff patient ratios Doctor 1/40 beds Professional nurse / Staff nurse or Nursing Assistant 4/ 11 per 40 beds Pharmacist 1 per 100- 200 beds Social worker 1 for > 40 beds Dietician Clinical Psychologist OT Audiologist Physiotherapist Data Capturer/ Admin Clerk 1 for 100- 200 bed Driver

PART C Supporting the caregiver Site appraisal Recruitment, retention and productivity in staff Additional personnel considerations Site appraisal Building layouts, Site information, Engineering and bulk services, Climate an sustainability considerations Future development Additional project studies, approval and requirements EIA Local authority submission Phasing and decanting

PART D_Operational narrative and user room requirements Patient daily schedule User room requirements Outpatient services Inpatient services Clinical support services for inpatients Patient support Allied healthcare services Support services Facilities management Administration and other (review various room types & reference to generic room data sheets and drawings)

PART E_Case studies Areas comparison of long-term XDR TB care facilities at: Bongani Hospital, Mpumalanga Tshepong Hospital, North West Modimolle Hospital, Limpopo Modimolle TB Hospital site layout patient rooms natural ventilation design Natural ventilation design principles study analysis Catherine Booth TB Hospital, KwaZulu-Natal Roof ventilation and windows concept drawings Two-bed patient rooms plan

CFD studies - Velocity vectors outlet side – 4 m/s external wind 1m/s = 3.6km/hr – 4m/s = 14.4k /hr

ANNEXURE 1 _Sputum booth The prototype of Sputum Booth; Technical information

IUSS - Applicability Gazette No prospective public sector 37348: R116, 17 February 2014 37790: R512, 30 June 2014 38776: R4141, 8 May 2015 prospective public sector Some relevant documents TB Services Infection Control Building engineering services etc. Waste Management Inpatient Care Primary Health Care

www.iussonline.co.za jnice@csir.co.za