Airborne Transmission: An Issue More Hospitals Should Heed

Transmission of airborne infectious disease is on the radar of every infection preventionist, but convincing a healthcare facility’s stakeholders to give adequate attention to the air quality needed to prevent transmissions is not always an easy task. Convincing “the powers that be” to commit to air quality is tough, but handling an outbreak of airborne infectious disease is even tougher.

Lack of maintenance is truly a national issue that endangers indoor air quality at healthcare facilities, says Andrew Streifel, MPH, a hospital environment specialist. Streifel has been associated with mitigating environmental infection control issues in more than 3,000 hospitals world wide. His expertise is in environmental infectious opportunistic microbes affecting immune compromised patients and employees.

“If it is not broken they wait till it breaks,” Streifel says of healthcare leaders. This is exacerbated, he said, by the fact that full-time maintenance employees are being laid off, even at reputable hospitals. That’s bad news for patients, and good news for microbes. The most common “opportunistic microbe” to look out for is aspergillus fumigates, Streifel emphasizes.

One of the first parts of his projects involves investigating the source of outbreaks. Streifel has worked with institutions in development of infection control risk assessments for construction, renovation and maintenance in critical-care facilities and has 34 years experience in infection control. When he arrives at a new location, he usually asks for the patient culture site.

“Blood, sputum, wound, urine, stool—usually when they say sputum I know the mouth caught the microbe so if bacteria we begin to look in the ice, sinks, showers and other potential by oral administration,” Streifel said. “If the opportunistic fungi show up on skin I think about laundry contamination, otherwise the fungal source is usually sputum. Looking for the source then has to do with the activity of the water either in the room or disruption during construction. The air quality issues are similar. Looking for environmental disruption, integrity of windows, maintenance procedures, local construction, construction in the fan system, etc. Sometimes we have had to resort to surface testing for fungal sources.”

His job involves a lot of questions, and some facility leaders aren’t fond of that.

“The medical staff are usually very supportive but sometimes the facility management is defensive because they have made cuts and now they might be getting burned with a problem,” Streifel said. “Ignorance has caused a cavalier attitude when construction disrupts the environment and staff feel at-risk patients can be housed close by. That did not work recently when patients were housed either side of a “tie-in” to another building. The pressure relationships were lost because the integrity of the building exterior was lost. Aspergillus infiltrated the patient room patient got infected and died. The facility manager was fired. They get very defensive and blame—that is no way to solve a problem.”

Fortunately, there are many ways that inside air can be protected from airborne pathogens. Some aspects that healthcare professionals can check right now to see if their systems are reasonably safe include finding out who is validating the performance of airborne infection isolation (AII) rooms, according to Streifel.

“We tested over 600 AII rooms and found deficiencies in all of them,” he said. “Functional performance testing and adherence to ventilation parameters will allow for healthcare workers to focus on other factors for preventing infection rather than ventilation. Ventilation should work as specified and that needs routine validation.”

To learn about negative-pressure anterooms, temporary containment units, and handling an airborne-infection-related pandemic scenario, see the accompanying Q&A.