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International Conference on Civil and Architecture Engineering (ICCAE-14) IOP Publishing
IOP Conf. Series: Earth and Environmental Science 1056 (2022) 012001 doi:10.1088/1755-1315/1056/1/012001

Prevention and Control of Airborne Infections; investigating

the efficiency of hospital design using (AIC) evaluation tool

Marianne Nabil Guirguis1, *, Rania Rushdy Moussa1

1
Architectural Department, Faculty of Engineering, The British University in Egypt, El-
Shorouk City, Cairo, Egypt
*
Corresponding Author Email: [email protected]

Abstract. Our world is resisting the new pandemic "severe acute respiratory syndrome
Coronavirus 2" (SARS-CoV-2) causing the disease known as COVID-19. To date, more than
two hundred and three million cases were confirmed out of who more than four million died.
Sharing data that will help the community to intervene with measures that will decrease the
spread of the virus and protect the population is an obligation. This will help the world cope with
this pandemic. This research aims to highlight the different criteria that will determine that the
building of a health facility is ready to control the infection of this virus and similar airborne
viruses. The research developed an evaluation tool that can be used by hospital administration to
assess the hospital building readiness to prevent and control airborne infection from the
viewpoint of architecture if it is an existing one or alternatively it can assess the design in case
of a new hospital building, determining required roles and responsibilities.

Keywords: Hospital design, Contamination control, Infection control checklist, Disease

transmission prevention, Infection mitigation, Infection evaluation tool
Abbreviations: (AIC) airborne infection control; (AIIR) airborne infectious isolation room;
(GUV) germicidal ultraviolet; (HAI) Hospital acquired infection; (ICU) intensive care unit;
(IPC) Infection prevention control; (PPE) Personal protection equipment.

1. Introduction
Coronavirus outbreak in 2020 raised questions about the preparedness of hospitals for pandemics,
especially airborne diseases. Infection control within a hospital is not simple and is a multidisciplinary
task, on one hand, comprising architecture and electromechanical works, in addition to administrative
and personal measures. On the other hand, it comprises the science of medicine and the respective
procedures. Creating sustainable hospital that can stand in front of airborne diseases is the main scope
of this research. Previous research tackled different ways to create sustainable building [1], but this
research intends to create evaluation tool to measure the efficiency of medical facilities against airborne
infections. All stakeholders should be playing harmoniously on site to eliminate HAI. The aim of this
article is to highlight the main criteria and practical design solutions that could serve as interventions to
limit disease spread within hospitals from the viewpoint of airborne infection control (AIC) principally
by developing an evaluation tool for AIC in hospitals.

2. Materials and Methods

The research adopts a theoretical method, by collecting the data from different standards and references.
Data has been categorized according to the nature of the different aspects and arranged to result an
evaluation tool in the form of a checklist assessing the existence of each aspect while evaluating its
condition.

Content from this work may be used under the terms of the Creative Commons Attribution 3.0 licence. Any further distribution
of this work must maintain attribution to the author(s) and the title of the work, journal citation and DOI.
Published under licence by IOP Publishing Ltd 1
International Conference on Civil and Architecture Engineering (ICCAE-14) IOP Publishing
IOP Conf. Series: Earth and Environmental Science 1056 (2022) 012001 doi:10.1088/1755-1315/1056/1/012001

Adding related Developing the a

Data Sorting out data Forming
classification under theoretical
collection around concepts categories
categories explanatory tool

Figure 1: Research Methodology (developed by author).

3. Disease transmission
Diseases transmit via direct or indirect contact. Transmission by direct contact may occur by person to
person contact through different body fluids and secretions, or by droplet spread, principally through
speaking, coughing or sneezing, when they reach the mouth and nasal mucosa, or conjunctiva of another
person [2]. Indirect contact comprises more types amongst which are contaminated things, food and
drink, animal to person contact, and airborne transmission [3] causing infection to the susceptible
persons. WHO determined that transmission of Covid-19 is via different modes of transmission by direct
contact, droplet, airborne, faecal-oral, blood borne, mother-to-child, and animal-to-human transmission
complicating the task of (IPC) It comprises hygiene, proper use of PPE and environmental sanitation,
and the evaluation of the readiness of the building itself. The last task is critical, as it has to mitigate
transmission of all types. However, one of the most difficult disease transmission modes to be controlled
is the indirect contact by airborne transmission [4] that occurs when the particulates of microbes from
the infection source remain suspended in the air carrying these pathogens to other persons who become
infected upon inhaling them if they are susceptible [5].

4. Design considerations in medical facilities addressing infection control

4.1. Functional zoning and space considerations

Each kind of space within a hospital has its own function generated from the occupants, durations, and
activities done in it. Separate zoning is essential to allow different approaches to the reduction of
aerosols of airborne infection. Transitions between different spaces should be well considered[6], and
separation between the blocks of the building is a higher level of zoning, by introducing gaps between
blocks of different function; hence, achieving maximum access control and separation between
functions, consequently a higher level of infection control [7]. To facilitate correct functional zoning,
modular design is highly recommended providing clarity and order. Hospital design integrates a
multitude of infrastructure systems. Also, there is a need to consider future improvements to the
different systems to accommodate technological advances and future extensions, thus, putting modular
design as a viable solution leading to adaptive hospital architecture with better performance [5]. Also,
functions of certain zones or spaces within zones are changed to accommodate arousing circumstances
such as viral outbreaks or activities expansion [8], hence, the design should allow this kind of flexibility,
such as changing certain zones to isolation rooms upon need[7]. This may be accomplished by dividing
an open space into smaller spaces by installing partitions, making it easier to adapt a current hospital
design in case of pandemics that are airborne without much work in the HVAC system. Airflow should
be reviewed to check for the modifications that will result from the added partitions[9]. One of the most
successful frameworks for zoning is the "three zones and two channels". The three zones (cleaning zone,
semi-contaminated zone, and contaminated zone) are separated from one another in a strict way without
any intersection between the three zones. Warning signage should be installed in a extremely noticeable
places at the doorways and entrances of the zones; The three channels (the medical personnel channel,
the patient channel, and the sample delivery channel) are also separated without any crossing circulation
[7].

4.2. Circulation
Circulation within a hospital is a critical topic within mitigating infection. The most important aspect is
a non-overlapping circulation with low intensity traffic[6]. The circulations that must not overlap are
that of patients with hospital staff. Physical mobility between different spaces was the only means of
communication previously; however, with technological advances in different installations for
interactive communication and monitoring systems, traffic flow intensity is minimized eliminating

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International Conference on Civil and Architecture Engineering (ICCAE-14) IOP Publishing
IOP Conf. Series: Earth and Environmental Science 1056 (2022) 012001 doi:10.1088/1755-1315/1056/1/012001

infection by transmission. Different circulation routes start by a good study of the quantity of entrances'
types and locations, and visibility of certain entrances in a hospital is important such as the main
entrance, the entrance to the emergency department and the outpatient clinic[5]. Stairways present a
potential of infections transmission via stack effect, hence, they are located far from the operation
theatres and the ICU preferably[5]. Enclosed pressurized stairwells can be adopted.

4.3. Natural ventilation:

The basic elements that determine effect of natural ventilation are the ventilation rate, airflow direction,
and pattern. The ventilation rate is directly affected by following factors: area of the window, climatic
and weather conditions, and relative position of the opening[10]. There are standards that present the
minimum accepted levels of hourly averaged natural ventilation rates, to mitigate airborne infection
transmission [9]. At times of airborne pandemics, natural ventilation is a key solution, as neither
infection methods nor efficient pharmaceutical treatments are scientifically determined conclusively, as
they are still under scientific investigation and research. Hence, it is strongly recommended to spread
awareness to the importance of substitution of re-circulated air in ventilation by natural air ventilation
through existing openings, whenever possible [10]. If natural ventilation is insufficient, then mixed
mode ventilation can be used. Exhaust fans present a possible complementary solution in this case to
improve the ventilation rate used[3]. During SARS outbreak it was determined that natural ventilation
reduced the intensity of airborne infection sources through the high ventilation rates with outdoor fresh
air[5]. This comes in accordance to the guidelines set by “WHO” which recommends minimizing the
need for air-conditioning, with windows that are designed effectively. Cross ventilation is also
recommended, where possible[8]. Hence, design solutions of the square or U-shape corridor that depend
totally on air conditioning are not the best solution as they withdraw the possibility of natural
ventilation[5]. Although natural ventilation has a multitude of advantages yet, it should be understood
that it is not the permanent substitute to mechanical ventilation. Natural ventilation should be available,
but mechanical ventilation is necessary due to its reliability in the first place, in addition to ease of
control of the indoor air temperature, humidity, and airflow path. Installation of filtration systems is an
advantage of mechanical ventilation. Hence, when designing a hospital, the worst case scenario for
natural ventilation is the absence of wind, which means that natural ventilation by itself cannot satisfy
the requirements, to underpin that mixed-mode or alternatively mechanical ventilation are obligatory
from the viewpoint of infection control and thermal comfort as well[9].

4.4. Finishing materials.

Sterile non-porous materials are recommended to minimize contamination and facilitate cleaning
including harsh scrubbing and cleaning with strong disinfecting chemicals. For finishing of walls and
ceilings, special paints should be applied that are washable in accordance to the standards. Also, high
solidity plaster should be used[5]. Hence, porous paints that cannot withstand any attack from any
organism should be avoided. As cleaning of disinfection materials of different chemical bases do floors,
hence, floor-finishing materials should be resistant to acids, alkali and salts. Additionally, they must be
easy to clean and designed with the minimum number of joints.

4.5. Partitions,
Metal panels in partitioning are a good solution in terms of flexibility, and sterility. However, these are
not the only factors in material choice of partitions, but their strength should be considered. At pandemic
outbreaks separate sinks can be added to be fixed on partitions outside the patients' room to enhance
hands hygiene procedures and avoid direct transmission by knobs [5].

4.6. Openings,
Designing the used door system and accessories in a hospital is be done from the viewpoint of infection
control. To achieve more sterility, the hands-free door operation is essential throughout a medical
facility. In patient rooms, using self-closing doors with stainless steel or polymer kick plates and push
plates will mitigate transmission of contaminated air and will minimize using hands. Details as the gap

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International Conference on Civil and Architecture Engineering (ICCAE-14) IOP Publishing
IOP Conf. Series: Earth and Environmental Science 1056 (2022) 012001 doi:10.1088/1755-1315/1056/1/012001

under a standard door should be considered as in AIIR, this gap is approximately 1cm[11]. For entrances
as emergency egress, automatic sliding doors that can be swung open providing an adequate solution.
Sliding doors without tracks with top-hung roller system provide a practical solution that has many
advantages; in addition to easy access, these doors reduce bumping of stretchers, patient beds and
different wheeled equipment thus decreases the joints in the floor. Material choice for the door should
be sterile such as doors with polymer panels cladding that provide cleanable surfaces. There are many
spaces in a health facility which tightness the room envelop is of due importance such as operation
theatres, ICUs, AIIRs. Hence, joints and penetrations should be designed critically in order to maintain
the airflow rate and pressure difference in these spaces [11].

4.7. Furniture.
The patient rooms use for quarantine must adequately ventilated, spacious single rooms with en suite
facilities and that means the toilet facility and the hand hygiene. Sometimes single rooms are
unavailable, hence, beds should space at least 1m in accordance to WHO. Also, the airflow path must
not be blocked with furniture. The furniture arrangement should consider social distance.

4.8. Signage.
The whole arrangement of the hospital should be set is clarity with a multitude of measures to
communicate certain message to the users. These messages will warn different types of users to go from
"clean" zones to "dirty" ones. Using signage, colors of the ground and/or walls, and automatic counting
sensors that give alert to administration if crowdedness occurs in areas as the waiting rooms.

5. Electromechanical considerations for infection control in hospitals

5.1. HVAC:
The ventilation systems are a means of infection transmission. Inadequate maintenance and low air
change rates put the health facility at risk of outbreaks [12]. Hence, in hospital HVAC system design,
ventilation of infected areas must be separated with specific filtration methods for AIC [13].

5.1.1. Supply air quality: The ventilation system should allow an option of disabling re-circulated
air, where outdoor air dampers introduce fresh air instead. The conditions of ventilation in terms of the
pressure relation to the other areas are set by "WHO"[8]. However, if the system used does not allow
this option like the split air-conditioning units, in this case, they will have to be turned off, as if operated
in a contaminated space, they will spread the airborne infection. But, this will need a way out to achieve
thermal comfort without increasing contamination risk such as natural ventilation through the existing
window openings [10].

5.1.2. Air filtration: It is another method to improve supply indoor air quality. Certain filters can be
added to the existing ventilation system as an intervention such as: HEPA filters, where HEPA is "High
Efficiency Particulate Air (or absorption)" [14] or electrostatic precipitator (ESP) filters, where
appropriate with an advantage of negligible pressure drop as they do not resist the airflow [13].

5.1.3. Ventilation rate: The role of the ventilation system from the perspective of disease
transmission control is to dilute the air from different pathogens. Previous research showed that room
air should be changed 10 to 12 times per hour when there is an infected patient with an airborne
infectious disease as opposed to a value of 4 to 8 times per hour for general wards [7].

5.1.4. Airflow distribution and pattern: The relative positions of supply and exhaust openings
determines the airflow distribution. For instance in AIIR ceiling-level exhaust was found to be better in
removing air impurities of different fine particles and aerosols than floor-level exhaust. furthermore, it
was determined that due to the thermal plume of the patient, these air contaminations flow upwards
more in an effortless way more than downwards [11]. In addition, the internal arrangements and
installations within each space should be taken care of as the curtains that are drawn for privacy or the

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International Conference on Civil and Architecture Engineering (ICCAE-14) IOP Publishing
IOP Conf. Series: Earth and Environmental Science 1056 (2022) 012001 doi:10.1088/1755-1315/1056/1/012001

partitions, as they will hinder the air distribution pattern within the space. Moreover, no furniture must
be located within the path of the airflow from the patient to the exhaust terminal [11].

5.1.5. Air pressure in different spaces: There are rooms that require positive, or negative, or neutral
air pressure according to the function [15]. Some spaces will require maintaining negative air pressure
such as one of the design scenarios for the AIIR. The direction of the airflow should take place from the
clean area towards the infection source and velocity of air should be less than 0.25 m/s. A self-closing
door is essential to maintain the pressure difference and a permanent pressure monitor is essential [15].
.However, this may attract secondary infections from adjacent spaces even though the design in case of
quarantine isolation rooms comprises an anteroom [16]. Awareness to this by the hospital management
affects decisions within the daily operations. Negatively pressurized anterooms leading to negatively
pressurized isolation rooms need to be entered by healthcare workers while wearing PPE for respiration.
Amongst such spaces that require negative air pressure are toilets [6].

5.2. Disinfection units and air purifiers

Using disinfection units in hospitals is another complementary solution in severe times of pandemics as
there is a diversity of technologies as mobile disinfections units that utilize UV light or hydrogen
peroxide vapor. Some of them use disinfectant fogging systems[17]. GUV was proved to be effective
with many microorganisms amongst which is Coronavirus, by mitigating aerosol transmission or UVGI
that removes or deactivates potential viral contamination from the re-circulated air[18]. In addition,
separate air filtration devices with the designated filters can be introduced to the different spaces. For
instance in areas where there are COVID-19, running air purifiers in the quarantine room may will
mitigate infection risk for caregivers and healthcare workers[19]. In addition to antivirus sterilization
and isolation equipment, that is important in isolation rooms to avoid cross infection through the medical
staff. These units come in a host of designs to suit the context.

6. Human factors:
Human factors encompass three levels; the state, the administrative, and the personal levels. The first
level comprises governmental strategies and policies dealing with the clear concise sovereign measures
on the scale of the population, whereas the second level is the administrative regulations and bylaws in
health facilities. It provides localized essential roles and responsibilities whose implementation
necessitates spreading awareness, providing personnel training plans and clear procedures for the
medical staff, caregivers, administrative staff, for patients and visitors. Finally, the last level is the
personal measures comprising awareness and behavioral training for the public to protective measures
including proper hygienic [4], and awareness of social distancing measures.

7. Results & Discussion: AIC (airborne infection control) evaluation tool

This research developed an evaluation tool to determine the deficiencies within any existing hospital
design in controlling airborne infection such as COVID-19. AIC evaluation tool can be considered as
an initial hospital design guideline checklist that new hospitals should consider its different aspects
during the design and construction phases to prevent spreading the airborne infections such as
Coronavirus. At the same time, when used by hospital management team, it stimulates increased
preparedness for such pandemics. The evaluation is based on yes or no; 'N' represents absence of an
aspect and 'Y' represents the existence of the aspect, knowing that the tool assesses the condition of the
existing aspect. The aspects condition range between 1 to 3; 1 is poor condition till 3 good condition.
The tool is divided into three sections; the first section is presented in Error! Reference source not
found.evaluating the design aspects assessing the hospital architectural design toward decreasing the
airborne infection transmission through five sub-aspects; zonings, modular design, design flexibility,
hospital circulation and the airflow. In this section of the tool, the assessment is conducted on the whole
hospital building.

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International Conference on Civil and Architecture Engineering (ICCAE-14) IOP Publishing
IOP Conf. Series: Earth and Environmental Science 1056 (2022) 012001 doi:10.1088/1755-1315/1056/1/012001

Table 1. AIC evaluation tool section 1, Checklist for designing aspects in each space.
Y N Action By
Aspects Sub-aspects
1 2 3 who
1.1 Zoning 1.1.1 Separate functions for zones
1.1.2 Clean air supply for each zone
1.1.3 Separation between building blocks
1.2 Modular design 1.2.1 Possibility of future extension
1.3 Design 1.3.1 Possibility of changing function
flexibility 1.3.2 Possibility of adding partitions
1.4 Circulation 1.4.1 Non overlapping circulation
1.4.2 Low traffic
1.4.3 Separation of entrances of different functions
1.4.4 Visibility of the main entrance to patients
1.4.5 Visibility the entrance to the outpatient clinic to
patients
1.4.6 Visibility of emergency entrance to patients
1.5 Airflow 1.5.1 Airflow direction in building from clean to dirty
zones
1.5.2 Separate functional zones have separate HVAC
systems
Further comments:

Table 2. AIC evaluation tool section 2, Checklist for interior design aspects of each individual space.
Zone Name ………………… Room Number …………………
Aspects Sub-aspects Y N Acti By
1 2 3 on who
2.1 Wall/ 2.1.1 Non-porous
partitions 2.1.2 Solid (can withstand harsh scrubbing & impact resistant)
2.1.3 Washable (can withstand cleaning with disinfecting
chemicals)
2.2 Availability labelling for departments to show restricted access signs
2.2.1
of Signage for certain users
2.3 Floor 2.3.1 Resistant to acids, alkali and salts.
2.3.2 Minimum number of joints
2.3.3 General condition: it has cracks or tear
2.4 Doors 2.4.1 Hinged door
2.4.2 Sterile , non-porous material
2.4.3 Washable withstanding disinfecting chemicals
2.4.4 Hands-free door operation
2.4.5 Self-closing doors
2.4.6 Stainless steel or polymer kick plates
2.4.7 Stainless steel or polymer push plates
2.4.8 Gap under a standard for airborne infectious isolation
room (AIIR) is approximately 1 cm
2.4.9 Door tightness
2.4.10 Sliding door on floor
2.4.11 Sterile , non-porous material
2.4.12 Washable withstanding strong disinfecting chemicals
2.4.13 Sliding doors without tracks with top-hung roller system
2.4.14 Self-closing doors via IR
2.5 Furniture 2.5.1 The minimum distance between beds is 1m
Further comments

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International Conference on Civil and Architecture Engineering (ICCAE-14) IOP Publishing
IOP Conf. Series: Earth and Environmental Science 1056 (2022) 012001 doi:10.1088/1755-1315/1056/1/012001

The second section in AIC evaluation tool is presented in Error! Reference source not found.,
evaluating interior design and finishing materials of different hospital zones to prevent the infection of
airborne viruses. For this section of the AIC evaluation tool, the assessment is conducted on each distinct
space.

The third section as presented in Error! Reference source not found., evaluates for each distinct
space the ventilation system and the air quality toward preventing airborne infection transmission.

Table 3:AIC evaluation tool section 3-Checklist for hospital ventilation & air quality aspects for spaces
Zone Name ………………… Room Number …………
Y N Act By
Aspects Sub-aspects
1 2 3 ion who
Natural 3.1.1 Is there a possibility of natural ventilation?
3.1
ventilation 3.1.2 Is there cross ventilation?
Mixed mode
3.2 3.2 Are there Exhaust fans?
ventilation
3.3 HVAC 3.3.1 Is there a AC Split system?
3.3.2 Does Air Changes per Hour meet standards?
3.3.3 Is the system efficient in delivering the outdoor air to
each location in the room? (to judge, check the
internal furniture, curtains for privacy, partitioning ,
& location of supply and exhaust)
3.3.4 Disabling re-circulated air option available
3.4 Air filtration 3.4.1 Re-circulated air is mandatory in the system
3.4.2 Are there filters for fine particulates
3.4.3 Are there ceiling-level exhaust?
3.4.4 Are there above floor level exhaust?
3.5 Room air 3.5.1 Positive pressure
pressure 3.5.2 Negative pressure
3.5.3 Neutral pressure
3.5.4 Does it meet the standards?
3.6 Disinfection 3.6.1 Is there a GUV?
units & air 3.6.2 Is there a UVGI?
filtration 3.6.3 Are there Disinfection units that use H2O2?
Further comments

8. Conclusion:
Due to COVID -19 pandemic outbreaks, the airborne infection spread in hospitals with a significantly
negative effect on the medical team and other patients due to the inappropriate hospital design. The
research develops an evaluation tool in the form of a checklist, to assess the efficiency of existing
hospitals toward preventing the spreading of airborne infection, thus helping the medical institution to
assess its efficiency toward facing the pandemic and other airborne viruses' attacks in the future. This is
achieved by identifying the weakness points that need to be enhanced and developed to improve the
efficiency of the design by reduction of spreading the infection within the medical facility.

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