Saturday, March 16, 2024

Why Resist Clean Air?

Barry Hunt spent a lot of time in hospitals with a knee injury, but managed to never catch Covid because he knows how to avoid it. 

It's possible for all of us to avoid it!! He wrote this thread in December 2021, but it's still very applicable. This is all from his thread:

I keep saying, "Someday I'll write a book" about the struggle to bring an engineering perspective to infection prevention and control in healthcare. For now I'll just write a thread.

Is there anything worse than knowing there are oceans full of icebergs ahead, how easy it is to engineer systems to detect and steer around them, but not being able to get the owners of the lines or anyone in command to listen as you blindly head straight for them? I've been advocating for engineering and standards for air, water and surfaces in healthcare facilities to ⬇️ disease transmission for over 30 years. The irony of being accused by out-of-touch ID/PH/IPAC/Epi of epistemic trespassing before and during the pandemic is gobsmacking. 

I started with single patient rooms. In pre-pandemic πŸ‡¨πŸ‡¦ we had the ⬆️ estimated healthcare-associated infection (HAI) rate in OECD, 1/10 inpatients, and the lowest beds and lowest single rooms/capita. We also had sicker patients.😠 Studies now show that single patient rooms cut infection rates in half. πŸ™‚ Ten years ago πŸ‡¨πŸ‡¦ began moving to primarily single patient rooms for new hospital builds - although not 100% because hospitals won't give up preferential private room billing to insurance companies. 😠 In 2007 we formed a small group of volunteers to create a πŸ‡¨πŸ‡¦ National Standard for Plume Evacuation, source control to prevent airborne transmission of disease in ORs. Despite nurses' complaints, we couldn't get support until doctors started getting genital warts in their noses. 

We helped ISO develop a similar global standard which was published in 2014. Because laser and electrocautery smoke is clearly visible, and there are now national and international standards the practice of source control in ORs is now well-accepted. Unlike smoke, our breath is not visible, and there are no national or international standards yet for pathogen-free air. However, the principle of air extraction would work in ICUs and patient rooms just as well as ORs. 

Copper was registered as an antimicrobial in 2008, 50 years after silver. Over the past 10 years countless studies showed efficacy, persistence, durability and safety of copper surfaces, but the ID community pushes back with objective conclusions like "too good to be true". /s While ID/IPAC has no budget on their own to implement engineering measures in hospitals, in πŸ‡¨πŸ‡¦ they can and most often do scuttle initiatives in Engineering and Facilities Management and Environmental Services departments to introduce new technologies and materials to ⬇️ HAIs. 

In 2011 I pursued the concept of combining continuous and high-frequency bioburden reduction of surfaces to prevent fomite transmission. Copper could provide 'continuous' ⬇️ on high-touch surfaces while UV, if automated, could provide 'high-frequency' ⬇️ on all surfaces. In 2014 we launched 'AutoUV', built-in fixtures that detected occupancy, monitored whether doors were open or closed, and dosed rooms every four hours and after every exit. As expected, it works. It can't not work. And after seven years in the field it's been shown to be extremely safe. 

Bathrooms can be the source of 1/2 of disease spread in hospital. C diff can be colonized in air after every toilet flush. Aerosols drift for minutes to hours. Intestinal and respiratory diseases are often spread through toilet aerosolization. AutoUV = bathroom source control. Today there are 1000's of units in use across πŸ‡¨πŸ‡¦, and the Ontario Ministry of Health has made AutoUV a standard of care for new hospital builds. MOHLTC now mandates and funds AutoUV. Hooray. But IPAC stubbornly pushes back AGAINST the use of AutoUV. 😠 

In other ironic news, Health Canada is cutting off use of open air UV in healthcare, including Upper Air UV, in the middle of an airborne pandemic due to a flood of household UV devices being sold retail and online that don't work, don't have safeties, or produce ozone. 😠 In 2014 I co-founded CHAIR, the Coalition for Healthcare Acquired Infection Reduction. Scientists, engineers, ID docs, and industry working together to engineer air, water and surfaces to ⬇️ HAIs. We naively thought we could achieve an 80% ⬇️ in preventable environmental HAIs with new technologies and materials. We knew legacy industry players in chemical disinfection would be a challenge. We had no idea the biggest battle would come from the ID/IPAC community itself. 

I watched in horror at the denial of airborne transmission of 2003 SARS at a plenary session in May 2014 in Toronto. Playing to the crowd in a very purposeful, dismissive, and comedic way, the speaker claimed "SARS is NOT airborne. The droplets fall to the floor within six feet." Dr Yu, Hong Kong Public Health, had just re-analyzed and re-published the Amoy Gardens study six months earlier on the 10 year anniversary reaffirming airborne transmission of SARS. When I challenged the speaker, he claimed "Oh, don't worry, I know him, he changed his mind". πŸ™„πŸ˜  In 2014 an ID doc from PHO presented at a Toronto IPAC Education Day. He claimed Ebola was DEFINITELY NOT airborne. When challenged with a study showing transmission between caged and separated lab primates he claimed, "Well monkeys have long arms. Besides, they can spit." In a follow-up: "There's airborne transmission of PRRV in hogs between factory farms kilometers away documented in Veterinary journals. "I don't read those journals." "Would you like me to send you some articles?" "Don't bother." They don't want to know. 😠

Hospitals are a global network of MDRO incubators. CDI and MRSA spread in hospitals before seeding community acquired versions. Sinks and drains are known sources of contamination, especially via aerosol route. Pathogens are getting more virulent including MDRO CPE/CRE/CPOs, and C auris. Water contamination, aerosolization, and bacterial, fungal, biofilm reservoir control = engineering. Progressive examples: Calgary Health Region - UV all incoming water - no Legionella. Self-disinfecting sinks - electrocatalytically split H2O into OH-, O-, O3, H2OH = disinfectant. Water contamination, aerosolization, and bacterial, fungal, biofilm reservoir control = engineering. Progressive examples: Calgary Health Region - UV all incoming water - no Legionella. Self-disinfecting sinks - electrocatalytically split H2O into OH-, O-, O3, H2OH = disinfectant. In Ontario, MOH now funds and mandates self-disinfecting sink and drain technologies. However IPCA/ID continues to push back AGAINST new technologies. πŸ™„πŸ˜ 

So why send this thread? Because the current struggle to recognize airborne transmission and the engineered solutions is part of an epic struggle. We've seen how much resistance there has been over the past almost two years. The entrenchment started a century ago as most of us know. But the struggle has been about much more than "airborne". It's a struggle for epistemic control, for critical thinking, for evaluation to first principles, the applied use of deductive reasoning, politics, economics, tension between careerism and Precautionary Principle. Many in ID/PH have fought against engineering measures but now are giving up on fighting the virus at all. 😠 It's important to not give in to the temptation of accepting "just live with it", "it's endemic now", "it's mild". NO. Not acceptable. 

CoVID is airborne. It's very manageable. Wear an N95 in occupied spaces until case counts are near zero. Make indoor air safe - ventilate, filter, UV. Set national and international standards for safe indoor air. Set a goal of elimination - regional, then national, then global. 

A BIG heartfelt thank you to the increasing number of heroes in ID/PH/IPAC/Epi who have bucked groupthink and siloes and legacy teaching and credentialism. It hasn't been easy for you to go against the flow and you deserve tremendous praise and thanks for your courage. πŸ™ And a big heartfelt thank you of course to Team Airborne, ZeroCoVIDCanada, World Health Network, scientists, engineers, doctors, and citizens everywhere who have fought to overcome adversity and agenda and misinformation to help others. πŸ™ . . . Florence Nightingale did a remarkable job in hospital design in the 1800s, especially with respect to prevention of airborne transmission.

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