Engineering Services Division Conference 2011 Port Dickson (28 - 30 May 2011)

Healthcare Facilities Design and Operational Issues in relation to Mold Problems

Khairul Azmy Kamaluddin Engineering Services Division Ministry of Health, Malaysia October 2010

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Contents
1. 2. 3. 4. 5. 6. 7. 8. 9. Importance of Indoor Air Quality Health Related IAQ Problems Fungal Biology Effects to Human Health Moisture Sources and Problems Sources of Building Humidity and Dehumidification Load Key Variables to Consider for Fungal Remediation Case Study Health Facilities References

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Indoor Air Quality (IAQ) in Healthcare Facilities

Critical in healthcare environment/hospitals

For prevention of cross-contamination, reduction and controlling infection to occupants For the promotion of comfort A factor in patient recovery In some instances, a major treatment

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Health Related IAQ Problems

Sick Building Syndrome Building Related Illness Hospital Acquired Infections

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Health Related IAQ Problems

Sick Building Syndrome (SBS)

Symptoms
Eye Irritation Mildest Dry Throat Rhinitis, Runny Nose Headache Fatigue Sinus Congestion Skin Irritation Shortness of Breath Cough Dizziness & Nausea
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Health Related IAQ Problems IAQ Parameters

Carbon dioxide, carbon monoxide, formaldehyde and tobacco smoke. Air temperature, air velocity, humidity. Mites, virus, bacteria and spores. Radon.

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Fungal Biology
The Key Factors That Influence The Metabolism And Survival Of Fungi/Mold

Water
(Moisture)

Temperature

Spores

Nutrient
Type and Concentration

Fungal Biology

Time for Spore Germination Under

Ideal Conditions:
Aspergillus & Penicillium,

48 72 hours Stachybotrys, 8 12 days

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Fungal Biology

Aspergillus niger
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Fungal Biology

Stachybotrys
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Effects to Human Health

Fungi can exert ill health effects by 3 major mechanisms: Allergy:Fungi produce beta glucans which have irritant
properties

Toxicity: Fungi produce a wide variety of toxic

chemicals called mycotoxins. potent carcinogens and hepatotoxins produced by some Aspergillus species

Infection: Fungi such as Candida, Histoplasmosis,

Cryptococcus, Blastomyces and Coccidioides can infect immuno-compromised people. Trichophyton, Candida and Malasezia commonly cause minor skin infections
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Effects to Human Health

Associated Adverse Human Health Effects
To multiple organs and body systems: 1) respiratory, 2) nervous, 3) immune, 4) hematological, 5) dermatological, etc

Possible life-threatening systemic infections to immuno-compromised patients.

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Moisture Sources and Problems

Stop Uncontrolled Moistures !

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Moisture Sources and Problems

Moisture Enters Building As: Liquid Water Water Vapor (Can change from vapor to liquid through condensation) Problems from Liquid Water Damages furnishings and building structure Supports microbial growth Provides surface wetness for evaporation, and increases indoor moisture load Problems from Water Vapor Elevates indoor dew point and relative humidity, increase VAC latent load High dew point increases condensation risk High relative humidity can result in occupant discomfort Accelerated microbial growth and dust mite population
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Uncontrolled Moisture in Buildings

Uncontrolled Moisture Within Building Contributes To:
Structural damage Occupant discomfort Unacceptable indoor air and environmental quality

Moisture Management Is A Shared Responsibility

Building design (Building, HVAC) Specification Construction Commissioning Maintenance Use
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Liquid Water Sources

Weather Rain, fog and snow, enter the building structure through roof and wall leaks Outdoor intake louvers may entrain rain droplets or snowflakes Ground water May seep into building through small cracks in basement walls and floors Leaking pipes and equipment Leaking appliances, valves and pipes can wet large interior or concealed areas Wet cleaning processes Floor mopping and carpet shampooing
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Liquid Water Sources

Evaporation from people Occupants produce water vapor at different rates, depending upon their activity level via respiration (ASHRAE Handbook) Vapor-pressure diffusion from outside Water vapor moves through wall materials Resulting moisture load is based on vapor pressure difference, surface area and material. Wet surfaces and processes Planned, as from pools, aquariums and fountains Unplanned, as from leaky pipes and dislocated condensation Cooking Occupants carry a significant amount of moisture into the building on their shoes and clothing during raining days
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Liquid Water Sources

Infiltration from outside Outdoor and indoor airs exchange through little openings on building envelope, and through large openings such as doors and windows Driven by mechanical ventilation, wind and stack effect Introduction via ventilation airflow VAC equipment draws in outdoor air for ventilation and to replace indoor air removed by fans for exhaust and processes Ventilation air contain considerable moisture, especially in hot, humid climates Water vapor in the ventilation air often represents the single largest source of moisture in a building
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Liquid Water Sources

When moist air is cooled below its dewpoint (i.e. cooled to a temperature at which it cannot contain all the water originally present), and if the cooling is caused by contact with a colder surface, the vapour changes to liquid droplets on that surface. This phenomenon is called condensation.

Condensation Condensate forms whenever moist air contacts a surface at a temperature below the dew point If concrete beneath flooring is much cooler than room temperature Uninsulated or misinsulated supply ducts and chilled water pipes above ceiling or inside unconditioned areas In unconditioned equipment-room, uninsulated surfaces of AHU, supply ducts, chillers, chilled water pipes, etc.
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Drink Can Phenomena

Condensation Occurs on the Surface When A Cold Surface Contacts Humid Air

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Sources of Building Humidity and Dehumidification Load

Ventilation from outside air Infiltration from outdoor air through enclosure cracks Air exchange through door operation Wet surfaces People Equipment and materials generating moisture Air permeation through walls Leakages

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Graph showing Sources of Humidity and Dehumidification Load

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Key Variables to Consider for Mold Remediation

Maintenance Focus
Identify total surface area affected Identify materials & furnishings affected Propose cleanup methods Bring proper personal protective equipment Propose proper containment methods

Engineering Focus
Locate source of the moisture to eliminate the mold agents Identify the root causes in engineering aspects Propose techniques to ENSURE NO potential for mold and fungal reoccurrence
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Case Study

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Examples of Health Facilities with Fungal/Mold Problems

KK Jenis 2 Ayer Keroh, Melaka KK Jenis 2 Beserah, Pahang KK Jenis 2 Kampar, Perak KK Jenis 3 Pasir Panjang, N. Sembilan KK Jenis 3 Padang Luas, Bera Pahang HSI , HosHAS, HUS, Hosp PutraJaya, etc Etc

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GAMBAR-GAMBAR KEADAAN INFESTASI KULAT KLINIK AIR KEROH

Bilik Pemeriksaan Mata:

Blackish mold is in germinating status.

Ruang Menunggu/Pendaftaran:
Outpatients crowd at waiting area. All air supply grills are spraying Mold spores into the hall.

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Klinik Warga Sejahtera

Mold is all over the walls and ceiling.

Bilik Rawatan Pesakit luar:

Mold is obvious on walls, column and ceiling.

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Bilik Pemeriksaan 7 (Aras Bawah)

Mold is in active grow stage. Musty odor persisted.

Bilik Pemeriksaan 5 & 8 (Aras Bawah)

Air is stagnant, but mold spreads all over ceiling. The Ceiling air return grill is heavily contaminated. Patches of fluffy mold grows from behind wall paint and from cracks.

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AHU of AIR-COND SYSTEM

System lacks control on temperature, air flow and humidity. The existing appearance suggested a poor house keeping and maintenance practice.

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Exam Room (PAP Smear), Poliklinik Heavy colony of mold all over the wall & ceiling

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Hospital Sultan Ismail, JB

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Hospital Umum Sarawak East Wing Ward

Mold on surface due to condensation and water leakages

Ceiling plenum of a room with FCU showing services

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Hospital Umum Sarawak East Wing Ward

Ventilation louvre with surface condensation

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Klinik Ayer Keroh: Type of Mold Identified

Lokasi Persampelan Pintu bilik kebal Kulat yang dikenalpasti Cladosporium sp.

Bilik Mesyuarat
In-house playground Bilik Temubual Depan Bilik Temubual

Cladosporium sp.
Confluent growth of non-sporulating fungi. Confluent growth of non-sporulating fungi. Confluent growth of non-sporulating fungi.

Air handling Unit Farmasi

Clasdosporium sp., Aspergillus niger Penicillium sp.

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Case Study
Klinik Ayer Keroh
Assessment of Indoor Air Quality
Purpose : To asses problems and to identify root causes of mold infestation and to enable decisions to be made on appropriate remediation and repairs, control measures, the provision of information, and the necessity for air monitoring as may be required to protect the health of employees and occupants who may be exposed to air contaminants at the place of work.

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Case Study
Klinik Ayer Keroh
Observations during Assessment (2008) Extensive fungus/mold contamination. Bioaerosol is obvious in the entire premise. Mold was in active grow status. Immediate Remediation necessary. Ventilation duct system is severely contaminated. Mold grows from building structure/furnitures. Gross surface condensation occurs after hours. Identified as Mold Damaged Building.

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Case Study
Further Technical Assessment Building ventilation system is unbalanced/overspecified. Temp too low and VAC maintenance not sufficient. Building structure is wet. Insufficient Wall Thermal Barriers(Stor Farmasi). Condensate water system in bad shape. Over use of cleaning detergent and air freshener. Many doors and windows left opened. Leakages of Roof, RC gutters and Floor Slab. Moisture ingress and outside air infiltration high.
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Case Study
Identified Risks Patients are exposed to high immunological risk Physicians and administrative staffs are exposed in hazardous environment for long hours. Medical equipment is contaminated. Pharmacy medicine dispatching under pollutant exposure environment. Technical speaking, evacuation necessary.

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Case Study
Recommendation Immediate remediation of VAC Clean up and decontamination Review the adequacy of VAC design, upgrade, modify and improve Rectify infiltration of moisture sources Control, maintain, monitor and provide good housekeeping

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Maximum Day:Hour

Jan 100 29:07

Feb 98

Location -- KUALA LUMPUR - MYS {N 3 7'} {E 101 33'} {GMT +8.0 Hours} Elevation -- 22m above sea level Standard Pressure at Elevation -- 101061Pa Data Source -- IWEC Data / WMO Station 486470 : Kuala Lumpur/Subang (2006) - Monthly Statistics for Relative Humidity % Mar Apr May Jun Jul Aug Sep 99 100 98 99 100 98 98 6:09 4:17 28:08 17:02 2:08 9:17

Oct 100 7:03

Nov 100 18:02

Dec 97 24:05

23:07 3:05

Minimum
Day:Hour

42
7:17

44

47

44
20:14

54 44
1:14 24:17

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3:17

53

46

52
23:14

55
17:14

54
16:14

7:14 2:14

11:14 2:17

Jan Maximum Day:Hour Minimum Day:Hour Daily Avg 33.3 18:14 21.0 7:08 26.9

Feb Mar 33.5 34.8 11:14 31:17 22.8 23.0 22:05 24:08 27.0 27.4

Apr 34.7 20:17 20.9 6:11 27.6

- Monthly Statistics for Dry Bulb temperatures C May Jun Jul Aug Sep 34.0 5.0 1:14 28:17 23.0 22.2 19:08 29:08 27.6 27.9 35.8 6:17 22.8 11:08 27.3 33.3 34.0 30:14 8:14 22.7 22.9 27:0812:08 27.1 27.2

Oct 34.0 6:17 22.0 18:07 26.7

Nov 33.0 6:14 22.6 7:05 26.7

Dec 33.0 1:14 21.9 31:05 26.4

- Maximum Dry Bulb temperature of 35.8C on Jul 6 - Minimum Dry Bulb temperature of 20.9C on Apr 6 - Monthly Statistics for Dew Point temperatures C May Jun Jul Aug Sep 26.6 26.0 2:11 17:13 21.3 20.0 11:17 18:20 26.1 13:20 15.0 3:17 28.8 25.0 7:17 10:11 20.9 20.3 1:20 17:05

Jan Maximum Day:Hour Minimum Day:Hour 25.6 14:17 17.2 7:11

Feb Mar 25.9 26.5 9:17 1:23 19.4 20.9 5:16 28:14

Apr 25.6 23:17 20.2 19:14

Oct 26.0 6:18 21.4 23:14

Nov 25.7 26:20 21.5 6:11

Dec 29.9 31:14 20.7 31:10

Daily Avg

23.1

23.0 24.2

23.6

24.0 23.7

23.8

23.7 23.2

23.6

23.5

23.1

- Maximum Dew Point temperature of 29.9C on Dec 31 - Minimum Dew Point temperature of 15.0C on Jul 3

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Klinik Ayer Keroh: Temperature and RH% Data

Jadual 1
Lokasi: Aras 1 Masa: 1.00 pm

Jadual 2
Lokasi: Aras 1 %RH TDP (C) 13.6 14.9 15.5 13.5 RHRM 69.4 75.7 63.6 59.8 Depan Farmasi Depan Lif Bilik rekod Bilik perancang keluarga TRM (C) 26 26 24.26 25 Masa: 5.45 pm Suhu Purata TSUR (C) 13.16 12.06 14.34 14.5 TDP (C) 21.3 20.6 19 19.8 %RH RHRM 76.8 73 74 74 Suhu Purata TRM (C) TSUR (C) 15.5 15.7 18.6 15.4

Depan Farmasi Depan Lif Bilik rekod Bilik perancang keluarga

19.72 19.66 22.2 21.5

Purata Suhu / Kelembapan di Luar bangunan: 28C / 85%

Purata Suhu / Kelembapan di Luar bangunan: 28C / 86%

Jadual 3
Lokasi: Aras 1 Masa: 7.20 am Suhu Purata TRM (C) TSUR (C) TDP (C) %RH RHRM

Jadual 1: Suhu dan kelembapan relatif di kawasan kaunter utama semasa pendingin udara beroperasi Jadual 2: Suhu dan kelembapan relatif di kawasan kaunter utama beberapa ketika setelah pendingin udara dihentikan Jadual 3: Suhu dan kelembapan relatif di kawasan kaunter utama beberapa ketika sebelum pendingin udara dihidupkan

Depan Farmasi 23.8 20.3 22.7 95 Depan Lif 23 20.3 22.9 99 Bilik rekod 24 19.8 22.5 92 Bilik perancang 24 16.8 21.3 86 keluarga Purata Suhu / Kelembapan di Luar bangunan: 23C / 100%

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Graf TSUR (C) dan TDP (C)

20 15 10 5 0 1 2 3 4 Lokasi Bilik TSUR (C) TDP (C)

Temp (TC)

Masa: 1.00 noon

1 - Depan Farmasi 2 - Depan Lif

Graf TSUR (C) dan TDP (C)

25 20

3 - Bilik rekod

Masa: 7.20 pm
TSUR (C) TDP (C)

4 - Bilik perancang keluarga

Temp (TC)

15 10 5 0 1 2 3 4

Lokasi Bilik

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Pilot Project
Recommended Corrections to Eliminate Mold Risks for Klinik Ayer Keroh Identify Root Causes for every affected areas. Apply engineering control solutions. -Building Envelope and VAC Elimination/Decontamination of Mold. One-off Total Remedial Action. Proper Maintenance/Operation of VAC. Monitoring of IAQ for Risk control. Inculcate good housekeeping
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Monthly Temperature Data For Ruang Menunggu Farmasi KK Ayer Keroh

Monthly % RH Data For Ruang Menunggu Farmasi KK Ayer Keroh

%RH 10 20 30 40 50 60 70 80

90

16:30 20:00 23:30 3:00:51 6:30:51 10:00 13:30 17:00 20:30 0:00:51 3:30:51 7:00:51 10:30 14:00 17:30 21:00 0:30:51 4:00:51 7:30:51 11:00 14:30 18:00 21:30 1:00:51 4:30:51 8:00:51 11:30 15:00 18:30 22:00 1:30:51 5:00:51 8:30:51 12:00 15:30 19:00 22:30 2:00:51 5:30:51 9:00:51 12:30 16:00 19:30 23:00 18 19 20 21 22 23 24

Weekly Temp. and %RH - Bilik Perancangan Keluarga KK Ayer Keroh

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Temp

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%rH

Example of Applicable Strategies for Condensation/Mold Prevention

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Automatic Control Reset Strategies

Example : Multi-stage Cooling
AHU Discharge Temp. (C)
18 16

Goal is to cool down room temperature without condensation to occur

14 12

Interval: 10-15 Min.

Cooling Time

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Desiccant Wheel Dehumidification

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Building Enclosure for Humid Climate Wall Analysis

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Wall Construction Type

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Wall Construction Type

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Thermal Insulating Coating / Painting

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Conductivity, Reflectivity and Emissitivity

For good insulation properties, the paint layer should have low conductivity values. Cool paints should exhibit high reflectivity so that light waves in the IR region may be reflected.
Material with low emissivity indicate that the radiation of heat energy back to the surroundings is low. Hence, for cool paints, it is desirable to have high emissivity

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Typical Airborne Sampling, Flow Control and Treatment Devices

Air Filtration
HEPA / ULPA Filter

Particle Sampling

Handhold Particle Counter

Air Particle Sensor

Portable Particle Counter

Bag-in/Bag-out multiple filters - Against biological, chemical & radiological materials

Room Airflow and Pressure Controls

Microbial Sampling
Microbial Air Sampler & Agar Media

Typical Equipment

Mold Remediation Respirator Mask Kit

Protimeter Moisture Measurement

Bio- Aerosol Impactor

Moisture Meter for esd_conference2011_kak wood, plaster/concrete, and gypsum

Non-destructively Concrete Moisture Meter , Data logger with 57 Infrared Thermometer

New Technology/Product
Hygenic Coating/Paint with active bacterial inhibiting properties and less VOC Non Chemical Metal based bacteria inhibitor technology surface coatings UVGI Thermal and vapor insulating panel/paint Radiant barriers and duct insulators
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The regulator: EPA Government enforcement: ACGIH The Remediator standard: IICRC The Property standard: ASHRAE Third party verification: Academic Lab.

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References

2007 ASHRAE - Handbook Chapter 7 2003 ASHRAE - Hospital and Clinics HVAC Design Manual

2006 AIA - Guidelines for Design and Construction of Hospital and Health Care Facilities
2005 NFPA Standard 99 - Standard for Health Care Facilities 2006 CDC - Infection Control Guidelines

2003 CDC - Guidelines for Environmental Infection Control in Health-Care Facilities

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References
WHO Interim Guidelines - Infection Prevention and Control of Pandemic - and Epidemic-Prone Respiratory Diseases in Health Care 2004 JCAHO Environment of Care Essentials for Health Care JCAHO: Joint Commission on Accreditation of Healthcare Organizations Aerobiological Engineering Handbook - Airborne Disease Control Technologies 2005 NFPA Handbook - Health Care Facilities Handbook

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Local Guidelines & References

Guidelines on the Control of Hospital Acquired Infection by Medical Services Division of MOH
Code of Practice for the Prevention of Infection & Accidents in Hospital, Laboratories & Post-mortem Rooms, 1987 Guidelines on Monitoring of Airborne Contaminant for Chemicals Hazardous to Health, DOSH, Min of Human Resources, Msia, 2002 Code of Practice on Indoor Air Quality, DOSH, Min of Human Resources, Msia, 2005 OSHA 1994 / JKR Arahan Teknik / Local Building Codes JKR Design Guidelines: 1)Garispanduan bagi Mencegah Pembentukan Kulat didalam Bangunan, 2) Arahan Teknik untuk mencegah Kulat Dalam Bangunan Kesihatan
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Conclusion

Surface Condensation, thus MOLD can be prevented; 1. By reducing moisture content of air, through improved ventilation, proper air conditioning or through dehumidification ( Surface Temperature above Air Dew point Temperature at all time) 2. By raising surface temperature, through insulation, better glazing or simply maintaining higher air temperature 3. By the selective use of vapour barriers

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Conclusion

Root Causes to be looked at mostly in combination, for surface condensation and mold growth problems:

1. Moisture Ingress and Infiltration 2. Temperature and %RH 3. Thermal Transmission 4. Vapour pressure

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Thank You

Q&A
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