1. 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

2. 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

3. 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SAHNorms (public sector) repealed
R158 (private sector) – outdated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

4. 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.”

5. 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.

6. 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 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.

7. 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

8. 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.

9. 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

10. 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)

12. 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

13. 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

14. 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

15. 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

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

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

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

19. 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

20. 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

21. 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

22. 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.

23. 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

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

26. 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.

27. 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

28. 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

29. PART B_Disinfection systems

30. 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 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.

31. 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.

32. 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

33. 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

34. 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

35. 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)

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

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

38. 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

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

40. 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

41. 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)

42. 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

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

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

45. 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