2. “My wife nearly died from a MRSA infection…” Creator of VidaShield Role of Contaminated Air in Healthcare Acquired Infections

3. “At first sight, I knew this product would help…” Infection Preventionist Role of Contaminated Air in Healthcare Acquired Infections

4. Maureen Spencer, RN, BSN, M.Ed, CIC Corporate Director, Infection Prevention Universal Health Services UHS has an Acute Care Division that provides high quality care at 26 hospitals in California, Florida, Nevada, Oklahoma, South Carolina, Texas and Washington, DC. UHS has a Behavioral Health Division that consists of over 300 centers/hospitals in the U.S. and England. Role of Contaminated Air in Healthcare Acquired Infections

5. Understanding the Role of Contaminated Air in Healthcare Acquired Infections Role of Contaminated Air in Healthcare Acquired Infections Objective:

6. Study shows abundance of human bacteria in indoor air, floor dust, and ventilation systems. 2 1 University of Leeds, Superbugs ride air currents around hospital wards, M. King, et al, 2 Human Occupancy as a Source of Indoor Airborne Bacteria, April 18, 2012, Airborne dispersion may play a role in air and surface contamination with MDROs, such as MRSA and Clostridium difficile, with subsequent contact and cross contamination 1 Have You Considered the Air? Role of Contaminated Air in Healthcare Acquired Infections

7. Pathogens Survive on Surfaces OrganismSurvival period Clostridium difficile 35- >200 days. 2,7,8 Methicillin resistant Staphylococcus aureus (MRSA) 14- >300 days. 1,5,10 Vancomycin-resistant enterococcus (VRE) 58- >200 days. 2,3,4 Escherichia coli >150- 480 days. 7,9 Acinetobacter 150- >300 days. 7,11 Klebsiella >10- 900 days. 6,7 Salmonella typhimurium 10 days- 4.2 years. 7 Mycobacterium tuberculosis 120 days. 7 Candida albicans 120 days. 7 Most viruses from the respiratory tract (eg: corona, coxsackie, influenza, SARS, rhino virus) Few days. 7 Viruses from the gastrointestinal tract (eg: astrovirus, HAV, polio- or rota virus) 60- 90 days. 7 Blood-borne viruses (e.g.: HBV or HIV)>7 days. 5 1. Beard-Pegler et al. 1988.. J Med Microbiol. 26:251-5. 2. BIOQUELL trials, unpublished data. 3. Bonilla et al. 1996. Infect Cont Hosp Epidemiol. 17:770-2 4. Boyce. 2007. J Hosp Infect. 65:50-4. 5. Duckworth and Jordens. 1990. J Med Microbiol. 32:195-200. 6. French et al. 2004. ICAAC. 7. Kramer et al. 2006. BMC Infect Dis. 6:130. 8. Otter and French. 2009. J Clin Microbiol. 47:205-7. 9. Smith et al. 1996. J Med. 27: 293-302. 10. Wagenvoort et al. 2000. J Hosp Infect. 45:231-4. 11. Wagenvoort and Joosten. 2002. J Hosp Infect. 52:226-7. Role of Contaminated Air in Healthcare Acquired Infections

8. High Touch Surfaces Role of Contaminated Air in Healthcare Acquired Infections

9. Prior Room Occupancy Increases Risk StudyHealthcare associated pathogen Likelihood of patient acquiring HAI based on prior room occupancy (comparing a previously ‘positive’ room with a previously ‘negative’ room) Martinez 2003 1 VRE – cultured within room 2.6x Huang 2006 2 VRE – prior room occupant 1.6x MRSA – prior room occupant 1.3x Drees 2008 3 VRE – cultured within room 1.9x VRE – prior room occupant 2.2x VRE – prior room occupant in previous two weeks 2.0x Shaughnessy 2008 4 C. difficile – prior room occupant 2.4x Nseir 2010 5 A. baumannii – prior room occupant 3.8x P. aeruginosa – prior room occupant 2.1x 1.Martinez et al. Arch Intern Med 2003; 163: 1905-12. 2.Huang et al. Arch Intern Med 2006; 166: 1945-51. 3.Drees et al. Clin Infect Dis 2008; 46: 678-85. 4.Shaughnessy. ICAAC/IDSA 2008. Abstract K-4194. 5.Nseir et al. Clin Microbiol Infect 2010 (in press). Role of Contaminated Air in Healthcare Acquired Infections

10. Aerobiology and Its Role in the Transmission of Infectious Diseases Journal of Pathogens Volume 2013 (2013), Article ID 493960, 13 pages Aaron Fernstrom 1 and Michael Goldblatt 2 Role of Contaminated Air in Healthcare Acquired Infections

11. Practitioners of all kinds agree that the airborne transmission of infectious disease is a problem. Just how big or urgent a problem, however, continues to be debated. For example, there is currently a wide range in the reported frequencies of airborne transmission in hospital-acquired infections (10–33%) A better understanding of the true contribution of airborne transmission to infection rates would allow hospital administrators to determine the degree to which they should commit resources to minimize this vector of disease transmission. Aerobiology and Its Role in the Transmission of Infectious Diseases Role of Contaminated Air in Healthcare Acquired Infections

12. MRSA infected/colonized pts. contaminate rooms, contribute to endemic MRSA Prospective study of 25 MRSA pts. Sampling of isolation rooms 53.6% of surface samples positive 28% of air samples 40.6% of settle plates Isolates identical or closely related in 70% of patients Environmental Reservoirs [Sexton et al, J Hosp Infect 2006]

13. Airborne Transmission MRSA counts remain elevated for up to 15 minutes after bed making Consider air ventilation & filtration Keep doors closed [Shiomori et al, J Hosp Infect 2002] Role of Contaminated Air in Healthcare Acquired Infections

14. Aerial Dissemination of Clostridium difficile spores BMC Infectious Diseases Katherine Roberts, Caroline F. Smith, Anna M Snelling, Kevin G. Kerr, Kathleen R. Banfield, Andrew sleigh and Clive B. Beggs Role of Contaminated Air in Healthcare Acquired Infections

15. Aerial Dissemination of Clostridium difficile spores Role of Contaminated Air in Healthcare Acquired Infections

16. An Outbreak of Surgical Wound Infections Due to Group A Streptococcus Carried on the Scalp The New England Journal of Medicine Timothy D. Mastro, M.D., Thomas A. Farley, M.D., John A. Elliott, Ph.D., Richard R. Facklam, Ph.D., Janet R. Perks, R.N., B.S., James L. Hadler, M.D., M.P.H., Robert C. Good, Ph.D., and James S. Pikka, M.D. Role of Contaminated Air in Healthcare Acquired Infections

17. An Outbreak of Surgical Wound Infections Due to Group A Streptococcus Carried on the Scalp Role of Contaminated Air in Healthcare Acquired Infections

18. Evidence in Support of Covering the Hair of OR Personnel AORN Journal John M. Boyce, M.D. Role of Contaminated Air in Healthcare Acquired Infections

19. Evidence in Support of Covering the Hair of OR Personnel Role of Contaminated Air in Healthcare Acquired Infections

20. Evidence in Support of Covering the Hair of OR Personnel Role of Contaminated Air in Healthcare Acquired Infections

21. AORN Journal, January 2014 In one study, dispersal of S aureus in the air increased sharply when staphylococcal dispersers were present in the OR, and the presence of nine dispersers were considered to be the cause of 19 postoperative wound infections.

22. Role of Contaminated Air in Healthcare Acquired Infections AORN Journal, January 2014

23. Molecular Epidemiology of Microbial Contamination in the Operating Room Environment: Is There a Risk for Infection? Charles E. Edmiston, Jr, Ph.D., Gary R. Seabrook, M.D., Robert A. Cambria, M.D., Kellie R. Brown, M.D., Brian D. Lewis, M.D., Jay R. Sommers, Ph.D., Candace J. Krepel, M.S., Patti J. Wilson, BSN, Sharon Sinski, B.S.N., and Jonathan B. Towne, M.D., Milwaukee, WI and Roswell, GA. Role of Contaminated Air in Healthcare Acquired Infections

24. Molecular Epidemiology of Microbial Contamination in the Operating Room Environment: Is There a Risk for Infection? Role of Contaminated Air in Healthcare Acquired Infections

27. Air Contamination and Infection Studies Role of Contaminated Air in Healthcare Acquired Infections

28. Skin contact: 40% of hand cultures positive 1 Environment contact: 45% of hand cultures positive 2 1. Stiefel U, et al. SHEA, 2010; Donskey CJ, 2. Eckstein BC. N Engl J Med 2009;360:e3. Acquisition of MRSA on Hands After Contact with Skin and Environment Role of Contaminated Air in Healthcare Acquired Infections

29. Positive broth enrichment cultures 33% physician workroom telephones 25% nursing workstation computers 33% physician portable computers 21% portable equipment Hand imprint cultures 0% for C. difficile Dumford D et al Am J Infect Control 2009;37:15-19 Role of Contaminated Air in Healthcare Acquired Infections Contamination of Environmental Sites Outside Patient Rooms with C. difficile

30. Setting: Medical ICU Contamination of HCWs hands or gloves after caring for VRE colonized patients HCWs were nearly as likely to contaminate their hands or gloves after touching the environment as after touching the patient Hayden MK et al Infect Cont. Hosp. Epid. 2008 Risk of Hand or Glove Contamination After Contact with VRE Patient or Environment Role of Contaminated Air in Healthcare Acquired Infections

31. Upper room air disinfection Air handlers & air conditioning units UV “robots” UV lamps in water treatment Biological safety cabinet UV has a History in Healthcare Role of Contaminated Air in Healthcare Acquired Infections

32. Area Micro Particle Decontamination Technologies – Labor Intensive Room Setup Role of Contaminated Air in Healthcare Acquired Infections

33. Conclusions More and more studies indicating air as a potential source of contamination that may result in healthcare-associated infections Studies show that hospital air is a potential route for transmission Individual air samples on average were 2-8 times more contaminated than surfaces Reducing the contamination in the air in some cases also reduces the settling of bacteria on surfaces – thus less chance of cross contamination on hands and equipment Use of continuous UV-C “air scrubbing” has a positive effect on reducing airborne bacteria and fungus Healthcare industry needs to validate and invest in innovative technology designed to treat the air

34. Introducing

35. VidaShield is a patented system designed to eliminate airborne pathogens and subsequent settlement on surfaces. It is the only active system that draws the pathogens into a UV Chamber that is positioned above the unit in the ceiling. There is low maintenance beyond installation, suggesting annual change of the UV-C bulb and quarterly change of the MERV 6 filter.

36. VidaShield functions 24/7/365 days with no harm to individuals in the rooms or areas where installed. Key areas include ICUs, NICUs, respiratory therapy areas, soiled rooms, isolation rooms, break rooms, pre and post-op areas, and EDs.

37. VidaShield is a standard 2”x4” fixture with down light (optional no light). It has a UV-C chamber positioned above the fixture in the ceiling, an unobtrusive use of UV technology at room level. Air is drawn from the room through an intake into the chamber at 50 cu. ft. per minute, accomplishing a 99.8% kill rate on most pathogens. The air recirculates back disinfected. For a 10x10 room with a standard ceiling, there are four cycles per hour.

38. VidaShield UV-C/UVGI mechanism is housed atop a standard footprint (2’x4’) ceiling light fixture Ultraviolet light is completely shielded, the room does not need to be vacant and can operate 24/7 in an occupied room Each unit houses four small fans (like those in a laptop computer) that pull room air into the system at 50 cubic feet per minute Air passes through the irradiation chamber, and then the cleaned air is pushed back into the room. The intake and exhaust vents are set at a 30 degree angle, which moves the air in a pattern that avoids repeatedly recirculating the same air How VidaShield works

39. Dr. Linda D. Lee, DrPH, MBA, Chief Science Officer American Green Technology

40. Can using active UV-C technology to treat the air reduce surface pathogens in a healthcare setting?

41. These environmental studies were designed to look at the relationship of surface and air contamination compared to the control and challenge areas for total bacteria counts in colony forming units. Technology Overview Can using active UV-C technology to treat the air reduce surface pathogens in a healthcare setting?

42. Sampling Process Can using active UV-C technology to treat the air reduce surface pathogens in a healthcare setting?

43. Patient room 425 is located in 4th Floor Oncology Unit. A positive pressure room that is approximately 220 sq. feet, there are 2 UV units installed. Air conditions in Patient Room 425 (challenge area) were the same pre- to post-test. The fan coil unit was operating, moving air in the room and the bathroom exhaust fan was operating as well. Air samples (surrounding area) were taken outside the patient room. A hallway example is shown below at the elevator lobby on the window ledge. The air environmental conditions in the surrounding areas (hallways, nurse’s station and elevator lobby) were very different pre- to post-testing. Room 425 was terminally clean prior to pre-installation sampling and it was not cleaned in post-installation sampling. Environmental Study Details - Children’s Oncology Unit Can using active UV-C technology to treat the air reduce surface pathogens in a healthcare setting?

44. 31 All units of measure are in raw colony forming units (cfu). Environmental Study Results - Children’s Oncology Unit Can using active UV-C technology to treat the air reduce surface pathogens in a healthcare setting?

45. Hallway Patient Room Evaluation Area Patient Rooms & Hallways in the intensive care unit Most patients in this area are on ventilators and contact isolation The unit is closed, protected by smoke doors with limited public access Study Criteria Determine placement and number of units (24 units) Take pre- and post-installation air and surface samples for total bacteria counts Independent lab analyzed the samples Environmental Study Details - Long Term Acute Care Hospital Can using active UV-C technology to treat the air reduce surface pathogens in a healthcare setting?

46. All Others 53% Environmental Study Results - Long Term Acute Care Hospital

47. Psychiatric unit (controlled access area) in emergency department 13 UV-C units to cover size of the room Pre- and post-installation air and surface samples for total bacteria counts Independent lab analyzed the samples Environmental Study Details - Acute Care Hospital, Psychiatric Holding ED Can using active UV-C technology to treat the air reduce surface pathogens in a healthcare setting?

48. All units of measure are in raw colony forming units (cfu). Environmental Study Results - Acute Care Hospital, Psychiatric Holding ED Can using active UV-C technology to treat the air reduce surface pathogens in a healthcare setting?

49. Individual air samples on average were 2-8 times more contaminated than surfaces Reducing the contamination in the air in some cases also reduces the settling of bacteria on surfaces It is important to understand the difference between the basis of design vs actual operations of the healthcare HVAC/Air Flow controls The use of UV-C at room level has a positive effect on reducing airborne bacteria and fungus Technology can make a positive impact on peoples’ lives The healthcare industry needs to validate and invest in innovative technology designed to treat the air More and more studies indicating air as a potential source of contamination that may result in healthcare-associated infections The air has been ignored for far too long and studies show that hospital air is a potential route for transmission Conclusions Can using active UV-C technology to treat the air reduce surface pathogens in a healthcare setting?

50. Questions Maureen, Linda and Jay