Air quality management in Indian healthcare

The Indian healthcare sector is growing at a rapid pace with wider coverage, more robust services and increasing expenditure, by the public as well as private players. The healthcare sector will see radical growth in the next 10 years. According to IBEF, the healthcare sector in India is expected to reach $372 billion by 2022. With the growing healthcare sector, there is an immense need for introducing green concepts and techniques in the healthcare sector for sustainable development.

Cll established the Indian Green Building Council (IGBC) in 2001 to facilitate Green Building movement. Since then, Green building movement has gained tremendous momentum & today, India has the second largest registered green buildings in the world.

The IGBC Green Healthcare Rating System
The IGBC has introduced Green Healthcare Rating System to address the national priorities. This rating system helps the designer to apply green concepts & techniques and reduce environmental impacts.

IGBC rating system addresses the following aspects:
• Indoor environmental quality
• Sanitation and hygiene
• Water conservation
• Energy efficiency
• Building materials and resources site selection and planning

Summary
This study describes the various aspects of indoor air quality management in the healthcare sector. It examines the unique air quality related challenges in medical centers and discusses effective strategies to combat the problem, while referencing the pioneering work of the Indian Green Building Council, Magneto Cleantech, and DewPoint Consultants at PGI Chandigarh. Since, there is a lot more to air pollution control beyond protecting occupants from dust, especially in a healthcare setting, this book covers a diverse set of topics, ranging from complex Hospital Acquired Infections to innovative, upcoming IAQ solutions, discussing the vision needed from the engineering stakeholders to protect people from this invisible killer. Finally, the book also mentions the visionaries in this new field who are striving to address the dangers of poor air quality in healthcare through increasing awareness and forward looking action.

Introduction
Surprisingly, the state of air quality in India is visible through the naked eye. The Indian air pollution is highly dangerous for the human body and the surroundings. Air quality has become a major concern for Indians and international visitors to India. Unfortunately, though, a large proportion of people are still unaware about air pollution. Despite the several harmful effects of air pollution on people, there are popular misconceptions, and the facts about air pollution are unknown to the layman.

Recently, people have started talking more about the dropping level of air quality in the Indian cities and the preventive measures needed because the situation has become critical. The 91 per cent of the world’s population breathes air the World Health Organisation (WHO) deems unsafe, every time one takes a breath, microscopic particles are being drawn into their lungs. They get into the bloodstream, causing cancers, strokes and heart disease, stunting children’s growth and development, and even reducing intelligence. The situation in India is much worse. A new study by Greenpeace has identified cities across the world with the highest levels of air pollution. The list is dominated by India, with seven of the worst 10 cities, and 22 of the worst 30. While the conversations about air pollution are being held on several platforms by government bodies and some organizations, the problem requires a long-term discussion and action. Air pollution needs to be tackled not only when it is clearly visible, but also when it is invisible and just as lethal.

Indoor air quality
India’s future economic growth will largely depend on harnessing the power of its massive workforce, which will require improving the health of employees and occupants for better productivity. Uncomfortable indoor conditions arise from poor indoor air quality. Stuffy air, for example, has been known to cause people to feel unwell or sluggish. Indoor air quality generally seems better than the quality of the air outside, where visible clouds of dark smoke are seen leaving cars, factories, and homes. The opposite can be the case when considering the concentration levels of pollutants in an enclosed space.

The Environmental Protection Agency (EPA) reports that air quality inside could be 2-5x worse than outside, based on its studies assessing indoor concentrations of airborne chemicals. Understanding and controlling common pollutants indoors can help reduce the risk of indoor health concerns. Also, reports suggest that each year more than 7 million people across the globe die because of exposure to indoor and outdoor air pollution. Of those 7 million premature deaths, 4.3 million are caused by exposure to indoor air pollution.

Pollutant sources
Particulate Matter: Particulate matter or PM (also called particle pollution) is the collection of all solid and liquid particles suspended in air many of which are hazardous. This complex mixture includes both organic and inorganic particles, such as dust, pollen, soot, smoke, and liquid droplets.

Particulate matters have a negative effect on the people constrained in the indoor space. These are particles that are so small that they can be inhaled and cause serious health problems. Some particles less than 10 micrometers in diameter can get deep into the lungs and some may even get into the bloodstream. Of these, particles less than 2.5 micrometers in diameter, also known as fine particles or PM 2.5, pose the greatest risk to health.

Airborne Microorganisms (Bio Aerosols): Airborne particles are a major cause of respiratory ailments of humans, causing allergies, asthma, and pathogenic infections of the respiratory tract. Airborne fungal spores are also important agents of plant disease, and the means for dissemination of many common saprotrophic fungi. For example, during a sneeze, millions of tiny droplets of water and mucus are expelled at about 200 miles per hour (100 metres per second). The droplets initially are about 10-100 micrometres diameter, but they dry rapidly to droplet nuclei of 1-4 micrometres, containing virus particles or bacteria. This is a major means of transmission of several diseases in humans such as Tuberculosis, Chickenpox, Smallpox, etc.

Bioaerosols are the tiny airborne particles present in the indoor air. They could be live or dead fungi and bacteria, their secondary metabolites, viruses, pollens, molds, plant fibres, etc. Their size varies fram between 1 to 100 pm in aerodynamic diameter. The viable bioaerosol particlescan be suspended in air as single cells or aggregates of microorganisms as small as 1-10 pm in size. Their concentration in indoor environments depends upon various environmental factors, such as temperature, humidity, seasonal variations, geographic location, characteristics of ventilation system and also on the type of building materials used. Identification and quantification of different airborne microorganisms in various indoor environments is necessary to identify the associated risks as these bioaerosols in indoor air environments may lead to both infectious (for example, tuberculosis, Pneumonia, Legionnaires disease etc.) and non-infectious diseases (asthma, allergy and SBS symptoms like upper respiratory irritative symptoms and rashes) depending upon their sources and origin. High bioaerosol concentrations in hospital environments may lead to hospital acquired infections.

Volatile Organic Compounds: Volatile organic compounds (VOCs) are emitted as gases from certain solids or liquids. VOCs include a variety of chemicals, some of which may have short-term and long-term adverse health effects. Concentrations of many VOCs are consistently higher indoors (up to ten times higher) than outdoors. VOCs are emitted by a wide array of common household products, including paints, thinners, adhesives, dry cleaning fluids, air freshners and many more. When VOCs combine with nitrogen oxides in the air, they form smog. Short term exposure to various VOCs may cause irritation in the eyes and respiratory tract, headaches, dizziness, visual disorder, whereas long term exposure may cause serious terminal diseases like cancer.

Indian environment and air pollution
India is a big tropical country and is famous for its diverse climatic features. It experiences a variety of climates ranging from tropical in the south to temperate and alpine in the Himalayan north. The elevated areas receive sustained snowfall during winters. The Himalayas and the Thar Desert strongly influence the climate of the country. This climate change has the potential to influence India’s biological system, however, its effects on human health are more extreme. Still falling under the category of developing nation with limited resources, we expect to face a host of health effects due to climate change, including air-borne and water-borne diseases.

Infectious disease distribution involves complex social and demographic factors. These include human population density and behaviour, housing type and location, quality of air, water supply, sewage and waste management systems, land use and irrigation systems, availability and use of vector control programmes, access to health care, and general environmental hygiene. Meteorological factors that influence transmission intensity of infectious diseases include temperature, humidity, and rainfall patterns. Social and demographic factors such as population growth, urbanisation, immigration, changes in land use and agricultural practices, deforestation, international travel, and breakdown in public health services have been mainly responsible for the recent resurgence of infectious diseases. The Intergovernmental Panel on Climate Change noted in its 2007 report that climate change may contribute to expanding risk areas for infectious diseases such as dengue and may increase the burden of diarrhoeal diseases, putting more people at risk.

The foremost reason behind the worst air quality in India is high frequency of dust storms. Chandra Bhushan, Deputy Director General at the Centre for Science and Environment (CSE), emphasised, “With the rise in global temperature the soil is going to become drier. So, the amount of soil that wind can carry is also increasing. With both the intensity of the wind and dryness of the soil increasing, the intensity of dust storm is going to further increase in the future. Climate change is intensifying all extreme weather events”.

“An increase in ozone precursors carbon monoxide and nitrogen oxide takes place after major dust events, which is likely to enhance surface ozone. Such processes also increase PM2.5 and PM10 and harmful greenhouse gases at the surface that has an adverse impact on human health,” researchers have concluded. “The dust storms have both short and long-term impacts and some of the short-term impacts can have very real consequences for human health. Mainly, the damage to air quality is seen to come from an increase in aerosol concentration, increases in respirable suspended particulate matter and also temporary fluctuations in tropospheric greenhouse gases like carbon monoxide and ozone,” explained Sudipta Sarkar, a scientist at the NASA Goddard Space Flight Center and a member of the research team, while speaking to India Science Wire.

Looking at the database’s ranking of particulate pollution in cities, 15 of the 20 cities with the highest levels are located in India. Gurugram tops the list with a yearly average of 135.8 micrograms per cubic meter of PM2.5, the most hazardous particle commonly measured. Frequent unhealthy levels of pollution from sources ranging from vehicles to the burning of coal and wood for cooking, dust storms, or forest fires affect most of the country. India’s hills and mountains also act as basins that trap toxic air over vast swaths of the country, sometimes making the air too dangerous to breathe.

Effects of air pollution
There is a lot about air pollution that Indians are still ignorant of factors that they need to take cognizance of and choices that they can make to improve their health and protect their loved ones.

Impact on humans: The most significant impact of the deleterious air pollution levels in India is on the health of its citizens, most particularly children. The problem is more pronounced for children who are grappling with respiratory disorders from the day that they are born. Before they can even develop strong immunity, children are exposed to the most harmful levels of toxicity possible that is leading to issues ranging from sleep apnea, disorientation, wheezing, coughing to impaired neurodevelopment and cognitive abilities, which can eventually trigger asthma and even childhood cancer.

Impact on the environment: Air pollution harms the environment in more ways than one and the most apparent of these is climate change. Many of the gases that cause air pollution also have a greenhouse effect because they trap the sun’s heat and push up the earth’s temperature. This has resulted in unusual weather conditions across the globe, including prolonged but warmer winters in Northern India and an unpredictable monsoon across the rest of the country. Further, such alterations in the climate, especially the rainfall levels, have terribly impacted the livelihood of a vast percentage of Indians who are primarily dependent on agricultural produce for survival. Therefore, the upshot of air pollution has a global climatic impact, making the world unsustainable for our future generations.

One of the most saddening narratives in this crisis is that of its repetitive nature, it is truly a vicious cycle that never seems to end. The primary cause of air pollution is the harmful emission of gasses from the ever-growing number of vehicles on Indian roads, crop burning and unorganised recycling of e-waste and plastics. However, many other similar activities have combined to make the problem a disastrous epidemic.

Indoor air quality in hospitals
Indoor air quality refers to the quality of air within and around building structures. Maintaining healthy IAQ is a challenging task due to rapid industrialisation and urbanisation.

Hospitals have an essential role in our society to ensure good health and vitality of the members of the community. The bad air quality in hospitals, however, can unexpectedly lead to new illnesses and poor health of the visitors and patients.

Hospital Acquired Infection (HAl) (also known as nosocomial infection) is an infection that is acquired in a hospital or other health care facility. Hospital-acquired infections are caused by viral, bacterial, and fungal pathogens. Poor indoor air quality (IAQ) in the hospital buildings is one of the main factors leading to HAI and can lead to other building-relaed illness such as headaches, fatigue, eye, skin irritations, and other symptoms.

Types of Hospital Acquired Infections (HAI)
• Bloodstream infection (BSI)
• Lower Respiratory Infections
• Urinary tract infection (UTI)
• Surgical site infection (SSI)
• Cutaneous Infections

Impact of HAI
Hospital Acquired Infection (HAI) leads to emotional and financial distress among the patients. HAI reduces the quality of life of patients and have a significant impact on the length of hospital stay and medical care cost. HAI also affects the hospital staff productivity leading to reduced work capacity or missed work entirely due to illness. HAls account for a large proportion of the harms caused by health care and are associated with high costs. Better evaluation of the costs of these infections could help providers and payers to justify investing in prevention.

Prevention of HAI
• Administration of antibiotic therapy and carrier staff to source patient to destroy the pathogenic agents.
• Proper sterilisation and disinfection.
• Disinfectant excreta and infected material.
• Regular hand washing.
• Surface sanitation.

Concerns to maintain IAQ in Hospitals
According to the WHO, at any given time over 1.4 million people across the globe suffer from a nosocomial or hospital acquired infections. Thus, healthcare facilities are under pressure to maintain good IAQ as many people are at risk because of the infectious diseases that can spread through air. Hospitals are under intense scrutiny by the government to adhere to strict regulatory standards to ensure the safety and comfort of patients, visitors, and staff.

Technologies for healthcare sector
Healthcare facilities are subject to microbiological airborne hazards that can cause infections in both patients and health care workers. Hospital acquired, or nosocomial, infections have been a persistent problem in hospitals and they can have complex multifaceted etiologies. It is possible that as much as a third or more of all nosocomial infections may be the result of airborne transmission at some point and, if so, air disinfection technologies may be able to reduce the nosocomial infection rate. Few such technologies are :

Central Air Cleaner (CAC)
The large-scale air pollution problem requires a central, integrated system for removing particles, infectious disease and carcinogenic gases in a natural manner at no recurring cost, no landfill, least environmental impact, with added energy saving benefits. Central Air Cleaner is based on Magnetic Air Filteration. It is a modular unit that can be attached to all types of old or new air conditioning (HVAC) systems to provide complete clean air to occupied spaces. This technology eliminates the need for a large number of stand alone type air purifiers that are inefficient and very expensive for purifying large spaces.

Photocatalytic oxidation
Photocatalytic oxidation (PCO) is an advanced air purification process through which volatile organic compounds (VOCs), bacteria, mold and fungus are destroyed by incorporating photonic ultraviolet (UV) energy combined with a catalyst creating an oxidising effect on the pollutants. APCO filtration system can be designed for a small room to effectively remove microbes, such as fungi and bacteria, and odors caused by organic elements, smoke, etc.

Ultraviolet Germicidal Irradiation
For over a century, scientists have known that certain frequencies of light have a devastating effect on microbial life. We now know that exposure to ultraviolet light in the range of 254 nm (UV-C band) disrupts the DNA of micro-organism thus preventing them from reproducing, thereby effectively killing them. UVGI — a well established disinfection technology is now widely used in hospitals and laboratories to sanitize instruments and work surfaces and to prevent the spread of potentially lethal airborne infectious diseases. Installation of germicidal UV light inside the air system prevents the growth of mold, which saves energy by improving heat transfer efficiency of HVAC Cooling Coil. A cleaner system also requires lessmaintenance.

Photo Hudro lonized Oxidation Plus
Photo Hydro lonized Oxidation Plus is a hybrid active air purification technology that produces friendly ionoplasmatic hydrogen based oxidizers that improve indoor air quality. It purifies the air and improves the health of the users.

Einstein discovered in the early 1920’s that in beaches and forest areas, the ion levels were very high as compared to cities. He found that ions are nature’s way of controlling mould, bacteria, viruses and odours. He concluded that the mountain fresh air and the ocean air make people feel better due to the higher levels of ions. PHIO+ recreates this natural bipolar ionization process in your home and buildings. This technology is highly effective against microbes, TVOCs and gases, particles (dust, dander, pollen),E-smog and odour.

Hybrid HEPA
Hybrid HEPA is an innovative airborne decontamination system that assures both, destruction of airborne microorganisms, high efficiency particulate arrestance — HEPA Class particle removal (>99.97 per cent for particle / 0.3 micron in diameter) and optimised molecular filtration. It entails several integral processes that operate in series through four distinct modules which transform contaminated air into safe, clean air for a wide range of air-treatment applications.

Hybrid HEPA technology goes beyond simple mechanical filtration and combines high efficiency particulate arrestance with destruction of the airborne microorganisms and molecular pollution removal for better control over the air. The keystone of the technology is a combination of non-thermal plasma in series with enhanced electrostatic filtration. The plasma serves to inactivate and charge airborne particulate matter thus rendering them inoffensive and more effectively captured through electrostatic forces.

Wall mounted air disinfection unit
The Wall Mounted Air Disinfection unit which can also be used as a floor standing unit, is a device designed for use in enclosed indoor spaces.

The unit replicates a process that occurs in nature through the degradation of Ozone by naturally occurring olefins.A bi-product of this reaction is the Hydroxyl Radical, a reactive Oxygen Species, which is highly unstable and reacts with bacteria, viruses and fungi by attacking most known species. The unit produces rapid disinfection in enclosed spaces and is also very effective at removing odours. It does all this without the need for air circulation or filtration and is quiet, compact and easy to operate. In contrast with some other products, it is not necessary to evacuate the room during sanitisation; the AD unit is designed to operate in busy lived-in environments. It is commonly used to protect against bacteria, viruses and fungi in hospitals, care centres, health centres, doctors’ surgeries, offices, hotels, gyms, changing rooms, sch ‘

Striking Solutions
Centres for Disease Control and Prevention (CDC)-funded, randomised clinical trial concluded that a combination of manual cleaning and measured-dose UV light results ina 30 percent reduction of infections for patients who stay in rooms previously occupied by infected patients.” This system uses a patented sensor 360 technology to provide total room disinfection.

• Light Strike Robots
• Micro Solution
• Scrub In

Air pollution in Chandigarh
Particulate matter levels at Chandigarh are quite alarming. The AQI last year in June went beyond the severe limit of 500 to 575. The air quality deteriorated because of dust storms in western India, particularly Rajasthan. 33 flights, including three international flights, from Chandigarh International Airport were cancelled. “Due to the disruption caused by bad weather at Chandigarh, all flight operations from Chandigarh were cancelled for June 14,” a communique from the airport public relations officer Deepesh Joshi said.

According to the Chandigarh Pollution Control Committee, if the level crosses 400, it can affect the respiratory system of even healthy people.Dr. Ravindra Khaiwal, Assistant professor, PGI, said, “People who suffer from dust allergies and those with a compromised immune system should avoid leaving their homes during worse AQI. Regular washing of hands and eyes is recommended”.

Project details
As hospital-acquired infection (HAI) and the awareness about air quality is getting elevated, PGI, Chandigarh being a responsible hospital & research center was looking to treat the air quality of the new building of hospital to protect people and their employees.

The visionaries of PGI, Dew Point and Magneto CleanTech realised that the project required unique solution keeping HAI as the center point of design. To protect its people, patients, and assets from infectious disease causing agents and to provide clean air, the team agreed to install Central Air Cleaners, a Magnetic Filterless Technology, which is highly efficient on particulate matter and cross infection causing agents. Since conventional filters only capture dust and bacteria, harmful microbes actually accumulate and proliferate on their surfaces, increasing the risk of these microbes being present in the air. The alternative was central air cleaning type (MCAC), electromagnetic filters had to be applied that not only capture tiny dust particles with high efficiency but also kill all microbes on the surface on the filters. These can have up to MERV 15 dust removal efficiency and proven kill rates of 99 per cent on E. Coli. UVGI (Ultraviolet Germicidal) and PCO (Photocatalytic Oxidation) are also known to deactivate and destroy bacteria and viruses upon exposure.