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Indoor Air 2010; 20: 284–297  2010 John Wiley & Sons A/S

www.blackwellpublishing.com/ina
Printed in Singapore. All rights reserved INDOOR AIR
doi:10.1111/j.1600-0668.2010.00653.x

Removal of exhaled particles by ventilation and deposition in a


multibed airborne infection isolation room

Abstract Removal of airborne particles in airborne infection isolation rooms is H. Qian1,2, Y. Li,1
important for infection control of airborne diseases. Previous studies showed
1
that the downward ventilation recommended by Centers for Disease Control and Department of Mechanical Engineering, The University
Prevention (CDC) could not produce the expected ÔlaminarÕ flow for pushing of Hong Kong, Pokfulam, Hong Kong SAR, China,
2
School of Energy and Environment, Southeast
down respiratory gaseous contaminants and removing them via floor-level
University, Nanjing, China
exhausts. Instead, upper-level exhausts were more efficient in removing gaseous
contaminants because of upward body plumes. The conventional wisdom in the
current CDC-recommended design is that floor-level exhausts may efficiently Key words: Airborne infection; Isolation room; Large
remove large droplets/particles, but such a hypothesis has not been proven. We droplets; Ventilation.
investigated the fate of respiratory particles in a full-scale six-bed isolation room Dr H. Qian
with exhausts at different locations by both experimental and computational School of Energy and Environment
studies. Breathing thermal manikins were used to simulate patients, and both Southeast University
gaseous and large particles were used to simulate the expelled fine droplet nuclei 2 Sipailou Road, Nanjing
and large droplets. Gaseous and fine particles were found to be removed more Jiangsu 210096
China
efficiently by ceiling-level exhausts than by floor-level exhausts. Large particles
Tel.: +86 13645186001
were mainly removed by deposition rather than by ventilation. Our results show Fax: +86 2583792722
that the existing isolation room ventilation design is not effective in removing e-mail: keenwa@gmail.com
both fine and large respiratory particles. An improved ventilation design is hence
recommended. Received for review 14 August 2009. Accepted for
publication 4 March 2010.

Practical Implications
Our findings of the relatively poor performance of fine-particle removal by the existing CDC design of isolation room
ventilation suggests a need for improvement, and the findings of the removal of large particles by deposition, not by
ventilation, suggest that floor-level exhausts are unnecessary, and that regular surface cleaning and disinfection is
necessary, thus providing evidence for maintaining isolation room surface hygiene.

airflow patterns, the air supply and exhaust should be


Introduction located such that clean air first moves to parts of the
Ventilation in isolation rooms is an important envi- room where health care workers (HCWs) are likely to
ronmental control method for infection control. work, and then flows across the infectious source and
Airborne infection isolation (AII) rooms are recom- finally into the exhaust. The conventional wisdom in
mended for infected patients with airborne diseases the current CDC-recommended design is that floor-
such as TB, measles and chickenpox (AIA, 2001; level exhausts may efficiently remove large droplets/
ASHRAE, 2003; CDC, 1994, 2005) and opportunistic particles exhaled from patients or produced by clinical
airborne diseases such as SARS and influenza (WHO, procedures. To the best of our knowledge, the recom-
2007). mendation of such an airflow pattern remains just a
The most recommended airflow pattern design is hypothesis, and it has not been proved. There has not
shown in Figure 1. The principle of the current AII been a systematic study of the effectiveness of this
room ventilation is to control the direction of airflow CDC-recommended design.
to prevent contamination of air in areas adjacent to the Reported nosocomial SARS outbreaks in hospitals
infectious source (CDC, 1994, 2005). For ÔoptimalÕ worldwide have reminded us of the need to create a

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Airborne infection isolation room ventilation

To aus
ex
ile t
h
t
Toilet

Isolation room

Anteroom

Transfer grille

Flo
or
lev
el
ex
hau
st

Corridor

Fig. 1 An illustration of the currently recommended ventilation design for airborne infection isolation rooms (WHO, 2007)

safe and healthy environment in hospitals. HCWs can tional methods. Three systems of exhaust location are
be at a high risk of infection during an outbreak of examined, i.e. floor exhausts only (the same as in the
airborne or droplet-borne diseases. During the 2003 existing CDC design), ceiling exhausts only, and a
SARS epidemic, over 20% of the infected individuals combination of both floor and ceiling exhausts. In the
were HCWs (WHO, 2003). The question of developing latter system, we only consider an exhaust air ratio of
an efficient air distribution system for isolation rooms 50:50%. The effectiveness of such a combined system is
is equivalent to asking how to remove simultaneously clearly demonstrated later without investigating other
the fine droplet nuclei and large particles. Fine droplet flow rate ratios. The conclusion from our multibed
nuclei are believed to be the transmission vector for study should also apply to single-bed isolation rooms.
airborne diseases, while large droplets are responsible A number of excellent related studies exist. These
in droplet-borne diseases. There have been many include the study of dispersion of droplets in a room by
studies on the performance of ventilation systems in Chao and Wan (2006), Chao et al. (2008), understand-
isolation rooms since the SARS outbreak, such as ing of body plumes by Zhu et al. (2006) and Gao and
evaluation of the ventilation performance in isolation Niu (2007), as well as the movement and removal of
rooms by field measurement (Li et al., 2007; Saravia particles in buildings (Bouilly et al., 2005; Lai, 2002;
et al., 2007), numerical investigation of ventilation Nazaroff, 2004).
performance for removing contaminants (Kao and
Yang, 2006; Lai and Cheng, 2007; Shih et al., 2007)
and laboratory experimental studies (Qian et al., 2006; Methdologies
Tung et al., 2009). Our previous studies showed that
Experimental design
the so-called downward ventilation could not produce
a ÔlaminarÕ flow as expected to push down respiratory Experiments were conducted in a full-scale AII test
gaseous contaminants to floor level and remove them room in the University of Hong Kong; see Figure 2.
from floor-level exhausts (Qian et al., 2006). The There were six beds, numbered from 1 to 6. Nine
interaction between upward body plumes and down- supply diffusers were installed in the ceiling, also
ward supply air streams creates a mixing flow pattern numbered from 1 to 9. Exhausts were available at the
in the room. The upper-level exhausts were shown to ceiling and floor level. The airflow rate for each exhaust
be efficient in removing gaseous contaminants when the could be adjusted. A typical downward ventilation
upward body plumes were considered (Qian et al., system (CDC, 1994) could be obtained when only the
2008). floor-level exhausts were open. To investigate the
The purpose of this study is to investigate in detail ventilation efficiencies of exhausts at different heights,
the fate of respiratory particles in a full-scale six-bed the ratio of ventilation rate of exhausts between ceiling
isolation room using both experimental and computa- and floor level were set to be 100%:0, 50:50%, and

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(a)

(b)

1 4

1 7 4

Column 2

2 5
2 8 5

Column 1

3 6

VSD
3 9 6
VSD

Fig. 2 (a) Illustration of the setup of the six-bed isolation room. The two levels of exhausts are shown. When the floor-level exhaust is
used, the system is referred to as the Centers for Disease Control and Prevention-recommended ceiling supply and floor return design.
(b) The floor plan showing Column 1 and Column 2 for placing the slides. All beds are numbered from 1 to 6 at the pillow location,
while all supply diffusers are also numbered from 1 to 9

0:100%, respectively. Three beds were placed along samplers were located in the mouth of each receiving
both the left- and right-hand sides of the room. The thermal manikin.
distance between beds at one side was 1 m. Two The particles were measured by two methods. The
vertical columns were located in the room for placing first was a 16-channel dust monitor (Grimm model
particle and temperature sensors. The supply ventila- 1.108; Grimm Aerosol Technik GmbH & Co. KG,
tion rate was 12 air changes per hour (ACH), while the Ainring, Germany), which could provide real-time size
exhaust was 13.2 ACH to maintain a negative pressure measurements of particles from 0.5 to 20 lm. The
in the room. sampling flow rate was 1.2 l/min. The second method
In order to reach the steady state for each test, we was to count and measure under a microscope the
waited for at least 4 h after switching on the ventilation particles deposited by impaction and settling on glass
system, and/or changing the heat sources including the slides placed in the air. Each slide was scanned under a
lights and manikins. Six thermal manikins were used to microscope (Leica DM1000; Leica Microsystems,
mimic patients, whose heat generation was set to be Wetzlar, Germany) and photographed with a high
76W, corresponding to a person at rest. During our resolution CCD camera (Leica DFC320; Leica Micro-
experiments, the tracer gas SF6 and particles were systems) connected to the microscope. The sizes of
released through the exhaled air of the source manikin deposited particles were analyzed using image process-
using a specially designed artificial lung with an airflow ing software developed in our laboratory (Sun et al.,
rate of 6 l/min, and exhaled air temperature was 2005). The Grimm dust monitor was calibrated by the
controlled at 32 ± 1.5C (Brohus, 1997). The Arizona manufacturer before the experiments, and the slide and
Test Dust (A4 Coarse) was used to simulate exhaled microscope method was evaluated in our laboratory
particles. The mode particle size was 80 lm. Six with particles of known sizes.
samplers for the tracer gas were available. One sampler For the slide and microscope method, the airborne
was located in the exhaust tube and another five particle concentration may not be fully revealed by the

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Airborne infection isolation room ventilation
r
ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
 ffi
number of deposited particles, because of the variation 0 0 0
pffiffiffiffiffiffiffiffiffiffi
in deposition rates of different-sized particles and the u ¼v ¼w ¼1 u02 þ v02 þ w02 =3 ¼ 1 2k=3 ð2Þ
difficulty in completely removing the ultra-fine particles
by cleaning the slide. This may be shown by two photos where k is the kinetic turbulent energy and V is the
of deposited particles taken by the microscope in the normally distributed number.
room with and without the particle source (not shown Different boundary conditions of particles are con-
here). Other possible sources of errors include the sidered including escape at exhaust outlets, reflection
particles overlying each other or small particles joining on vertical walls and ceiling, and entrapment on the
up to form a larger one. We counted only the particles floor, skin of inpatient and beds.
larger than 3 lm. A commercial CFD software package, Fluent 6.2,
with user-defined functions was used for numerical
simulation. CFD simulations were carried out as
Numerical simulation
follows. First, we obtained the steady solutions for the
Computational fluid dynamics (CFD) was used to airflow without particles. The particles were then
investigate the airflow pattern and particle dispersion. injected into the ward through the mouth of the source
The turbulence effect was considered by using the manikin at a rate of 192 particles per second for each
Re-Normalization Group k- model (Ferziger and particle size. Particles were injected for a period of 800 s,
Peric, 2002). The second-order upwind scheme was and a total of 153,600 particles were injected into the
used for discretizing the convection terms. isolation room during this period for each particle size.
The air velocity from the supply diffuser was set the
same as the average velocity in the experiment,
Susceptible exposure index
obtained by dividing the airflow rate by the diffuser
area. The geometry of the simulated isolation room We define an exposure index for the susceptible
was the same as the experimental ward. All walls were receptor to quantify the relative intake of substances
well insulated in the experiment and assumed to be exhaled by the source patient or the infectious host
adiabatic in CFD simulations. Non-slip boundary (Nazaroff et al., 1998). The susceptible exposure index
conditions are applied to all walls. We assumed that is defined as e ¼ CCri C
Cs , where Cr, Ci, and Cs are
s

half the heat from the manikins was transferred concentrations at the exhaust (return), in the inhaled
through convection (Brohus, 1997). The particle tra- air of the susceptible (i.e. receiving individual), and at
jectory was calculated by a Lagrangian method. To supply, respectively. When steady state conditions are
simplify the calculation, the following assumptions considered in our experiments, the average concentra-
were made, i.e. the heat and mass exchange between air tions can be used. The tracer gas (SF6) concentration of
and particles were neglected, and the influence of supply air was zero (0), thus e ¼ CCri . Note that our
particles on airflow was also neglected. defined susceptible exposure index  is the reciprocal of
The Lagrangian method calculates the trajectory of the personal exposure index defined in Brohus (1997).
each particle by solving the following equation: A high susceptible exposure index  also means a high
exposure by the susceptible to the airborne substances
! ! ! ! exhaled by the infected.
du p
¼ Fdrag þ Fg þ Fa ð1Þ
dt
Results and discussion
! !
!Fdrag is the drag force, Fg is the gravity force,
where
Airflow patterns in the isolation room
and Fa is the additional force, which includes the
pressure force, virtual mass force, Basset force, Brown- Figure 3 shows the predicted air velocity field in a
ian force, and SaffmanÕs lift force. The pressure force plane through patient 2 and patient 5 in the test room
and virtual mass force are sufficiently small and so they (see Figure 2). The main flow characteristics are
are ignored (Zhao et al., 2004). dominated by the downward negative buoyancy flow
The turbulent dispersion of particles was predicted through the nine diffusers, agreeing with smoke visu-
by integrating the trajectory equations for individual alization results (not shown). The supply air velocity is
particles using instantaneous fluid velocity, sufficiently low so that negative buoyancy dominates
u ¼ u þ u0 ðtÞ. The random effects of turbulence on the supply air stream. The supply air stream becomes a
particle dispersion are modeled by the discrete random negative thermal plume, instead of a negatively buoy-
walk method. The values of u¢, v¢, w¢ are assumed to ant jet. The two-side diffuser air streams tend to bend
obey a Gaussian probability distribution, and the toward the heads of the manikins. This is possibly
fluctuating components are assumed to be isotropic. because of the rising manikin thermal plumes. The
The fluctuating velocity components can be obtained plumes rise to the ceiling level, bend at the wall corner,
as follows: and then join the supply air stream. When the exhausts

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(a)
1 m/s

(b)

1 m/s

(c)

Fig. 3 Predicted airflow pattern in the isolation room in the plane of patient 2 (left) and patient 5 (right). (a) Floor-level exhausts;
(b) ceiling-level exhausts, and (c) both levels of exhausts with airflow rate ratio of 50:50%

are located at the lower level (Figure 3a), we have the into the supply air stream. When the exhausts are
traditional CDC isolation room design. The supplied located at both upper and lower levels (Figure 3c), part
diffuser air streams fall vertically to floor level and of the rising plumes go directly to the exhausts at the
leave the room through the floor-level exhausts. upper level, but the airflow rate through the upper
Although there is an overall downward flow pattern exhaust is lower than that in Figure 3b. The downward
in the corridor area, the airflow pattern in the vicinity middle supply air stream bends towards the left in
of the beds is generally mixed. This is because of the Figure 3a,c, but towards the right in Figure 3b. The
interaction between the plume generated by the ther- boundary conditions are symmetrical, and the resulting
mal manikin and the air stream from the supply asymmetrical flows may be because of the nature of the
diffuser. complex flows. The airflow is mixed, but not fully
The plume generated by the thermal manikin is mixed, as there is no room-scale recirculation. The
above the torso and head. When the exhausts are upward plume will help to bring gaseous pollutants to
located at the upper level (Figure 3b), part of the rising ceiling level and a ceiling exhaust will improve the
plumes go directly to the exhausts and part is entrained removal efficiency.

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Airborne infection isolation room ventilation

Measured susceptible exposure index for removing gaseous pollutants Measured particle distribution
Table 1 summarizes the measured susceptible expo- The preceding results were for gaseous pollutants,
sure index of the receiving manikins for the gaseous which can be a model for fine droplet nuclei with a
pollutants. In a fully mixed room, the pollutant diameter of <10 lm. Our further work focuses on
concentration everywhere in the room should be the particles larger than 10 lm. The concept of D90 is
same as in the exhaust. Thus, the measured suscep- used here to show the particle-size distributions,
tible exposure index in a fully mixed room should be measured by the slide and microscopy method. In a
unity (1). The measured susceptible exposure index is particular size distribution, 90% of the total number of
between 0.24 and 4.35. The air in the six-bed ward particles has a diameter less than the value of D90.
here is not as well mixed as in the two-bed Figure 4 shows the measured D90 (only particles
experimental ward (Qian et al., 2008). The position larger than 3 lm are considered in the calculation as
of the source patient significantly influences the discussed earlier) and the measured number of parti-
susceptible exposure index. Generally, the susceptible cles at different locations in the ward with different
exposure index is lower when the distance between exhaust locations. The number of particles at each bed
the receiving and source patient is greater. For the is the measured value at the manikin head location.
last row of results in Table 1, bed 4 is directly facing Each setting is referred to as (exhaust location; source
the source patient; hence, the susceptible exposure patient bed number) where Ôexhaust locationÕ refers to
index is 4.35 at bed 4, suggesting a very high floor, ceiling or both levels of exhausts of ratio
exposure level. 50:50%, and Ôsource patient bed numberÕ refers to
Comparatively, the overall susceptible exposure bed 5 or 6.
index for the gaseous pollutants is the lowest when The distribution of particles is found to be influenced
the exhausts are at ceiling level. For the two ceiling by the distance from the particle source. The particles
exhaust results shown in Table 1, the measured are found to be larger at locations close to the source.
susceptible exposure index is mostly much lower Smaller particles are easily influenced by airflow and
than unity (1), except for those beds close to the can travel a long distance, while large particles tend to
index (source) patient bed. This result suggests deposit on surfaces close to the source.
that the ventilation removal effectiveness in this The difference in D90 and the total number of
ventilation design is better than the fully mixed particles along each vertical column is not as obvious
design using the momentum jet principle. The result as that at two different horizontal locations, as the two
may exclude the need to study other types of columns are mostly further apart in Figure 4 for each
ventilation systems based on the mixing principle setting. The results measured by the particle counter
for isolation rooms. (Grimm model 1.108) also indicate that particle sizes
The results are also consistent with the conclusions do not differ at different heights of 0.5 and 2 m from
of our previous study (Qian et al., 2008). The upward the floor for different settings (data not shown).
flow plume appears to play a significant role in The trends in the results measured by Grimm and
transporting the exhaled pollutants upwards so that those measured by microscope are similar, but the
they can be removed through the ceiling-level exhausts. values are different. The D90 measured by Grimm is
When the airflow rate is 50% through the ceiling-level between 7.5 and 10 lm, while the D90 measured by
exhausts and 50% through the floor-level exhausts, the slides and microscope is between 10 and 23 lm. There
susceptible exposure index is generally less than that are two possible explanations. The first is that in the
with only floor-level exhausts and greater than that slide and microscope method, only particles larger
with only ceiling-level exhausts. than 3 lm are counted. The second is that large
particles with a large settling velocity are more easily
deposited on the slide, while fine particles with a low
Table 1 Measured susceptible exposure index of each patient of the tracer gas in a full- settling velocity easily follow the airflow and bypass
scale 6-bed test isolation room when the index patient (the source) is in bed 5 or 6. The
index patient (the source) is facing upward if not stated otherwise
the slide, suggesting that the slide and microscope
method may not measure all the fine particles. The
Exhaust location Bed 1 Bed 2 Bed 3 Bed 4 Bed 5 Bed 6 large particles deposited on the slide may overlie
smaller particles. Some small particles may join
Floor level only 0.90 0.86 0.89 0.83 2.08 Source
Ceiling level only 0.24 0.28 0.52 0.26 1.22 Source together and become a single larger one, although
Both floor and ceiling levels 0.79 0.68 0.61 1.16 2.00 Source efforts were made to identify this situation in our
Floor level only 1.01 0.85 0.65 2.00 Source 0.92 imaging processing. Thus, the number of large parti-
Ceiling level only 0.76 0.60 0.45 1.92 Source 0.57
cles may have been overestimated, and the number of
Both floor and ceiling levels 0.97 0.81 0.63 2.78 Source 0.79
Both floor and ceiling levels* 1.28 0.91 0.70 4.35 Source 0.42 small particles may have been underestimated. How-
ever, the measurements by both the Grimm and
*Index patient facing bed 4. microscope methods suggest a greater influence by

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2.5 2.5
Column 1 Column 1
Column 2 Column 2
2.0 2.0
4521 5508

Height (m)

Height (m)
1.5 1.5 C2
4785 9472
C1
13 14 4482 Source
1.0 1.0 VSD

C2
VSD

13 23
0.5 C1 0.5
13 Source
VSD
VSD

0.0 0.0
11 12 13 14 15 16 17 18 19 20 21 22 23 0 2000 4000 6000 8000 10,000
Diameter of particles D90 Particle numbers
(a) [Floor exhaust; Source bed 6] (b) [Floor exhaust; Source bed 6]

2.5 2.5
Column 1
Column 2 Column 1
2.0 2.0 Column 2

Height (m)
Height (m)

1.5 1.5
1854 2922
C2
10 13
1.0 1.0 1440 4316
C2
16 C1
13 Source
C1 3197
0.5 0.5
VSD
VSD

18 Source
VSD
VSD

0.0 0.0
8 10 12 14 16 18 20 22 0 2000 4000 6000 8000 10,000
Diameter of particles D90 Particle numbers
(c) [Ceiling exhaust; Source bed 6] (d) [Ceiling exhaust; Source bed 6]

2.5 2.5
Column 1
Column 1 Column 2
2.0 Column 2 2.0
Height (m)
Height (m)

1.5 1.5

4106 6991
1.0 15 17 1.0 C2
C2 4985 11827
15 19 C1
0.5 0.5 7821 Source
C1 VSD
VSD

18 Source
VSD
VSD

0.0 0.0
8 10 12 14 16 18 20 22 0 5000 10,000 15,000 20,000 25,000
Diameter of particles D90 Particle numbers
(e) [Both levels exhaust; Source bed 6] (f) [Both levels exhaust; Source bed 6]

Fig. 4 The vertical distribution of the measured D90 of particles (a, c, and e) and the vertical distribution of the measured particle
number (b, d, and f) along two columns shown in Figure 2(b) at different settings. The numbers shown in a bed are the corresponding
values in a position close to the manikin head in the bed. Each setting is referred to as (exhaust location; source patient bed number)
where Ôexhaust locationÕ refers to floor, ceiling, or both levels of exhausts of ratio 50:50%, and Ôsource patient bed numberÕ refers to bed
5 or 6

the horizontal distance from the source and lesser the source patient was facing upwards. These were
influence by the difference in height. calculated by adding up the total particles removed or
It should be noted that the absolute values (D90 or suspended by each mechanism after the particles were
the particle number) shown in Figure 4 cannot be released continuously for 800 s.
compared between two different experimental settings Looking at the last column, which shows the
because of possible differences in the particle source percentage of particles suspended in the air, 31.5% of
strength. It was not possible to maintain a constant the 1-lm particles remain in suspension in the air in the
particle release rate during our experiments. system with only floor-level exhausts when the source
patient is in bed 5, compared with only 5.2% for the
system with only ceiling-level exhausts. The ceiling-
Predicted fate of particles using CFD
level exhausts are clearly shown to remove fine particles
Table 2 summarizes the percentage of particles sus- (<20 lm) more efficiently than the floor-level
pended in the air and those removed by two major exhausts. This is because of the upward plume as
mechanisms, i.e. by ventilation through the exhaust previously discussed. For particles larger than 30 lm,
outlet(s) and by deposition on different surfaces, when both the floor- and ceiling-level exhausts performed

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Airborne infection isolation room ventilation

Table 2 The fate of particles released by a source patient in bed 5 or 6 (measured by the percentage of the total released particles), including deposition on skin, beds, and the floor, and
ventilation removal by exhausts at the ceiling and/or floor level, and suspended in the room air. The source patient is facing upward

Receiving Source
Source Diameter manikins manikin All Ceiling- level Floor-level Suspended
patient Exhaust (lm) skin (%) skin (%) beds (%) Floor (%) exhausts (%) exhausts (%) in air (%)

Bed 5 Floor-level exhausts 1 0.8 2.0 10.1 26.3 – 29.4 31.5


5 0.8 1.9 9.8 27.6 – 28.9 31.0
10 0.6 1.8 8.8 33.0 – 19.4 36.4
20 0.2 2.9 7.3 51.8 – 19.4 18.4
30 0.1 11.6 14.7 50.5 – 11.9 11.2
40 0.0 32.7 27.5 28.3 – 4.7 6.8
50 0.0 75.4 15.4 4.9 – 0.5 3.8
Ceiling-level exhausts 1 0.1 0.8 1.3 2.0 90.4 – 5.2
5 0.1 0.8 1.4 2.2 90.4 – 5.1
10 0.2 0.8 1.2 2.5 90.4 – 4.9
20 0.3 0.9 1.3 4.6 88.9 – 4.0
30 0.8 2.4 2.3 4.5 86.0 – 4.0
40 1.0 9.6 5.0 2.3 77.4 – 4.7
50 0.3 38.7 11.4 1.9 41.6 – 6.1
Both-level exhausts 1 1.2 2.3 8.8 20.7 27.8 11.4 27.8
5 1.2 2.2 8.7 21.9 27.5 11.4 27.1
10 1.1 2.2 8.0 26.5 26.5 10.9 24.8
20 0.8 2.5 8.2 44.5 20.1 7.3 16.5
30 1.9 5.4 14.1 45.0 17.7 3.9 12.1
40 2.5 13.7 19.6 39.4 14.2 2.6 8.0
50 0.5 47.5 17.5 24.1 4.5 0.9 5.0
Bed 6 Floor-level exhausts 1 0.5 4.3 9.7 17.7 – 28.0 39.9
5 0.5 4.3 9.4 18.9 – 27.4 39.5
10 0.6 4.0 8.7 21.6 – 27.1 38.1
20 0.5 7.1 10.9 31.0 – 23.5 27.0
30 0.2 13.4 13.6 40.8 – 15.9 16.2
40 0.0 29.5 17.2 33.4 – 5.4 14.5
50 0.0 51.1 7.5 24.3 – 0.9 16.1
Ceiling-level exhausts 1 0.3 1.8 0.8 11.6 65.8 – 19.7
5 0.3 2.0 4.1 11.8 65.7 – 16.1
10 0.2 2.0 3.7 13.0 66.3 – 14.8
20 0.1 3.2 3.4 12.6 67.0 – 13.7
30 0.0 6.0 4.9 16.9 61.2 – 11.0
40 0.0 15.3 6.1 14.1 53.3 – 11.2
50 0.0 44.4 3.7 4.5 33.4 – 14.1
Both-level exhausts 1 0.5 3.6 5.6 9.7 49.5 7.8 23.5
5 0.5 3.5 5.4 10.2 49.4 7.3 23.8
10 0.5 3.9 5.2 11.7 49.0 6.7 23.0
20 0.7 6.1 7.9 13.9 46.8 5.2 19.4
30 0.9 11.4 12.4 13.0 43.6 3.0 15.6
40 0.6 22.3 14.0 8.5 38.1 1.4 15.1
50 0.1 49.5 9.7 2.4 20.5 1.1 16.8

similarly, with about 5–10% remaining in the air. It through exhausts. Only 0.5% of the 50-lm particles are
can be seen later that most of these large airborne removed by the exhaust in the floor-level system when
particles were recently released into the air. The the source patient is in bed 5. In contrast, under the
performance of the system with exhausts at both levels same conditions, 41.6% of the 50-lm particles are
was surprisingly close to that of the system with floor- removed by the exhaust in the ceiling-level system.
level exhausts only. More than 50% of the 50-lm particles are removed
It is interesting to examine the amount removed by by deposition on skin, beds, and floors in the ceiling-
the exhaust air, i.e. by comparing the values in the level system. However, more than 90% of the 50-lm
columns for ceiling-level exhausts and floor-level particles are removed by deposition in the floor-level
exhausts in Table 2. Of the 1-lm particles, 90.4% are system. The floor-level exhausts are not more efficient
removed by exhaust in the ceiling-level system, while in removing large particles than the ceiling-level
only 29.4% are removed by exhaust in the floor-level exhausts. The results strongly suggest that in the
system when the source patient is in bed 5. existing CDC-recommended system, the large parti-
For large particles, the number of particles removed cles are removed mainly by deposition, not by venti-
by deposition is much greater than by ventilation lation. This disproves the common belief that the

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Qian & Li

CDC-recommended system pushes down the large particles in the air is much lower than the number of
particles to floor level, so that they are removed by fine particles in each setting. A greater number of large
the floor-level exhaust. particles can be found at a height of around 1.0 m, as
Based on our discussion with the HCWs and the height of the exhaling mouth is 1.06 m when the
infection control experts, floor-level exhausts are also source patient faces upwards and 1.1 m when the
inconvenient because they are usually located close to source patient faces sidewards. Most of the suspended
the bed heads, where the space is valuable for clinical large particles are close to the exhaling mouth; see
purposes. Ceiling-level exhausts would free up this Figure 6.
space for clinical use.
Figure 5 shows the vertical distribution of the
Predicted dispersion of particles using CFD
predicted number of suspended particles in the entire
room. For each setting, exhausts at ceiling level seem to The above-observed pattern of the fate of particles is
be the most efficient in removing fine particles, while closely related to the particle dispersion pattern. In
exhausts at floor level seem to be the least efficient in Figure 6, we show the suspended particles after they
removing them. The number of suspended large are continuously released for 800 s, for both the ceiling

2.5 2.5

2.0 2.0
Height (m)

Height (m)
1.5 1.5

1.0 1.0
[Floor exhausts; Source bed 5]
[Ceiling exhausts; Source bed 5] [Floor exhausts; Source bed 6]
0.5 [Both exhausts; Source bed 5] 0.5 [Ceiling exhausts; Source bed 6]
[Both exhausts; Source bed 6]

0.0 0.0
0 1000 2000 3000 4000 5000 6000 7000 0 1000 2000 3000 4000 5000 6000 7000
Particle number Particle number
(a) (b)

2.5 2.5

2.0 2.0
Height (m)

Height (m)

1.5 1.5

1.0 1.0
[Floor exhausts; Source bed 5]
[Ceiling exhausts; Source bed 5] [Floor exhausts; Source bed 6]
0.5 [Both exhausts; Source bed 5] 0.5 [Ceiling exhausts; Source bed 6]
[Both exhausts; Source bed 6]

0.0 0.0
0 1000 2000 3000 4000 5000 6000 7000 0 1000 2000 3000 4000 5000 6000 7000
Particle number Particle number
(c) (d)

2.5 2.5

2.0 2.0
Height (m)

Height (m)

1.5 1.5

1.0 1.0

0.5 [Floor exhausts; Source bed 5] [Floor exhausts; Source bed 6]


[Ceiling exhausts; Source bed 5] 0.5
[Ceiling exhausts; Source bed 6]
[Both exhausts; Source bed 5] [Both exhausts; Source bed 6]
0.0 0.0
0 1000 2000 3000 4000 5000 6000 7000 0 1000 2000 3000 4000 5000 6000 7000
Particle number Particle number
(e) (f)

Fig. 5 The vertical distribution of the predicted number of particles of different sizes in the isolation room. The source patient is facing
upward. (a) Particle size is 1 lm and source patient in bed 5; (b) particle size is 1 lm and source patient in bed 6; (c) particle size is
10 lm and source patient in bed 5; (d) particle size is 10 lm and source patient in bed 6; (e) particle size is 50 lm and source patient in
bed 5; (f) particle size is 50 lm and source patient in bed 6. Each setting in the figure is referred to as (exhaust location; source patient
bed number) where Ôexhaust locationÕ refers to floor, ceiling, or both levels of exhausts of ratio 50:50%, and Ôsource patient bed
numberÕ refers to bed 5 or 6

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(a1) dp = 1 mm (b1) dp = 1 mm

(a2) dp = 10 mm (b2) dp = 10 mm

(a3) dp = 20 mm (b3) dp = 20 mm

(a4) dp = 50 mm (b4) dp = 50 mm

Fig. 6 The birth time of suspended particles in the air after 800 s since the first particle was released. A birth time of 0 (zero) second
means that the particle was released 800 s ago. A birth time of 800 s means that the particle was just released. Hence, the exhalation jet
is seen as a ÔredÕ air stream from the source patient. The particles removed by either deposition on surfaces or ventilation through
exhausts are not shown. (a) Floor exhaust; source patient bed 5, facing upward; exhalation velocity 0.12 m/s. (b) Ceiling exhaust;
source patient bed 5, facing upward; exhalation velocity 0.12 m/s

and the floor exhausts. The source patient is in bed 5, patient. There are fewer suspended particles in the air
facing upward with an exhalation velocity of 0.12 m/s. for the ceiling-level system (left-hand figures) than for
A low exhalation velocity suggests that the exhalation the floor-level system (right-hand figures). Small par-
air stream behaves as a thermal plume, which joins the ticles of 1–20 lm disperse throughout the entire room,
body plume. The particles were colored by the birth with smaller particles dispersing more evenly. Large
time; that is the time at which the particles are released particles (e.g. 50 lm) stay closer to the source. Only the
to the ward. A birth time of 800 s means that the very young large particles remain in the air in Figure 6,
particle has just been released; hence, the exhalation jet suggesting that large particles are removed by surface
can be seen as a ÔredÕ air stream from the source deposition.

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Qian & Li

(a1) dp = 10 mm (a2) dp = 20 mm

(b1) dp = 10 mm (b2) dp = 20 mm

(c1) dp = 10 mm (c2) dp = 20 mm

(d1) dp = 10 mm (d2) dp = 20 mm

Fig. 7 The birth time of suspended particles in the air after 800 s since the first particle was released. (a) Both-levels exhaust; source
patient bed 5, facing upward; exhalation velocity 0.12 m/s. (b) Both-levels exhaust; source patient bed 6, facing upward; exhalation
velocity 0.12 m/s. (c) Floor-level exhaust; source patient bed 6, facing upward; exhalation velocity 0.12 m/s. (d) Ceiling-level exhaust;
source patient bed 6, facing upward; exhalation velocity 0.12 m/s

Figure 6 clearly demonstrates that the ceiling-level tions, i.e. with both levels of exhausts in Figure 7a,b,
exhausts are efficient in removing fine particles, while and with the source patient in bed 6 for Figure 7b–d.
the removal of large particles is relatively less depen- In all cases, the source patient is facing upward with a
dent on the ventilation system, as its major removal low exhalation velocity of 0.12 m/s. The 20-lm parti-
mechanism is by surface deposition. Fine particles can cles have a tendency to stay close to the corner bed
remain suspended in the air for a long time and be source in Figure 7b–d.
transported a long distance, whereas large particles The mode of exhalation and the position of the
cannot. source patient are also important. In Table 3, we
In Figure 7, the dispersion patterns for the 10- and include two other situations when the source patient
20-lm particles are compared for four other condi- is located in bed 6 and also faces sideways to bed 5.

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Airborne infection isolation room ventilation

Table 3 The fate of particles released by a source patient in bed 6 (measured by the percentage of the total released particles) at two exhalation velocities 0.12 or 2.00 m/s, including
deposition on skin, beds, and the floor, and ventilation removal by exhausts at the ceiling and/or floor level, and suspended in the room air. The source patient is facing bed 5

Exhaled Diameter Receiving Source manikin Ceiling-level Floor-level Suspended


Exhaust velocity (m/s) (lm) manikins skin (%) skin (%) All beds (%) Floor (%) exhausts (%) exhausts (%) in air (%)

Both-level 0.12 1 1.4 2.6 3.2 4.0 65.8 3.7 19.4


exhausts 5 1.5 2.7 3.5 4.5 64.0 4.1 19.8
10 1.7 4.7 4.7 5.7 56.6 5.2 21.4
20 1.7 19.8 11.4 8.4 40.5 4.8 13.4
30 0.3 57.7 13.2 7.7 14.8 1.5 4.8
40 0.0 71.7 18.3 2.7 0.2 3.2 4.0
50 0.0 26.4 68.1 1.4 0.0 0.2 3.9
2.00 1 6.1 1.4 7.5 11.9 33.8 10.4 28.9
5 6.0 1.1 7.7 12.9 34.7 10.9 26.7
10 2.2 0.8 4.8 18.1 34.7 10.6 28.7
20 7.2 0.3 12.0 31.2 18.9 11.4 18.9
30 9.8 0.3 19.6 35.7 15.0 6.3 13.3
40 13.3 1.1 30.6 32.4 8.9 3.8 9.8
50 9.6 1.3 56.5 21.7 3.6 4.4 2.8
Ceiling-level 0.12 1 0.6 2.0 2.8 2.1 79.6 – 13.0
exhausts 5 0.7 2.1 3.1 2.4 76.2 – 15.4
10 0.9 3.0 4.1 3.2 75.6 – 13.2
20 0.6 8.9 8.0 7.1 66.1 – 9.3
30 0.0 30.6 8.0 10.7 41.1 – 9.6
40 0.0 49.4 18.8 15.9 12.3 – 3.6
50 0.0 28.3 57.9 10.4 0.3 – 3.1
2.00 1 1.8 1.9 5.7 7.3 60.1 – 23.2
5 1.7 1.6 5.3 7.9 59.0 – 24.5
10 1.9 0.9 5.0 11.1 57.9 – 23.2
20 2.1 0.7 6.1 25.9 48.9 – 16.3
30 2.5 1.9 11.0 25.6 48.6 – 10.3
40 4.1 1.9 19.4 18.8 47.5 – 8.3
50 3.5 1.3 36.9 15.6 36.2 – 6.4
Floor-level 0.12 1 2.3 2.4 9.9 14.0 – 20.8 50.6
exhausts 5 2.2 2.4 9.0 14.8 – 20.5 51.1
10 2.3 2.9 8.9 21.4 – 22.7 41.7
20 1.9 6.8 14.0 33.8 – 22.3 21.2
30 0.2 18.4 23.0 36.7 – 12.5 9.1
40 0.0 33.6 41.6 13.3 – 8.4 3.0
50 0.0 19.6 77.3 0.4 – 1.7 1.0
2.00 1 2.8 2.7 9.9 15.6 – 22.3 46.7
5 2.7 2.6 9.5 16.6 – 22.4 46.2
10 3.1 2.4 9.0 21.2 – 23.9 40.5
20 4.8 4.4 16.6 24.6 – 23.6 26.1
30 6.6 10.2 28.5 21.3 – 17.1 16.2
40 6.4 15.3 36.3 12.8 – 17.7 11.5
50 1.9 5.7 43.2 7.7 – 36.8 4.7

As the source patient faces sideways, the exhalation isolation room with a downward supply and three
jet does not follow the upward body plume; see different exhaust designs. The existing CDC-recom-
Figure 8. When the exhaled air velocity is 0.12 m/s, mended ventilation design is not found to be effective
the exhaled jet can be captured by the body plume. in removing both fine and large respiratory particles
However, when the exhaled velocity is 2.0 m/s, the for the purpose of infection control. For gaseous
exhaled jet can escape the plume capture. This pollutants and fine particles, the system with only
phenomenon results in a greater percentage of ceiling-level exhausts in the isolation room can remove
particles suspended in the air for a high exhaled the pollutants and fine particles more efficiently than
velocity of 2.0 m/s than that for a low exhaled the system with only floor-level exhausts and the
velocity of 0.12 m/s. system with exhausts at both levels. For large particles,
deposition played a more important role than ventila-
tion in removing these. The floor-level exhausts did not
Conclusions
appear to be much more efficient in removing large
We have presented a detailed experimental and numer- particles than the ceiling-level exhausts.
ical study of the distribution of the exhaled particles Comparatively, the ceiling-level exhausts are found
and gaseous pollutants in a full-scale experimental to be the most efficient in removing exhalation

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Qian & Li

(a1) dp = 1 mm (a2) dp = 50 mm (d1) dp = 1 mm (d2) dp = 50 mm

(b1) dp = 1 mm (b2) dp = 50 mm (e1) dp = 1 mm (e2) dp = 50 mm

(c1) dp = 1 mm (c2) dp = 50 mm (f1) dp = 1 mm (f2) dp = 50 mm

Fig. 8 The birth time of suspended particles in the air after 800 s since the first particle was released. (a) Both-levels exhaust; source
patient bed 6, facing towards bed 5; exhalation velocity 0.12 m/s. (b) Both-levels exhaust; source patient bed 6, facing towards bed 5;
exhalation velocity 2.00 m/s. (c) Floor-level exhausts; source patient bed 6, facing towards bed 5; exhalation velocity 0.12 m/s.
(d) Floor-level exhausts; source patient bed 6, facing towards bed 5; exhalation velocity 2.00 m/s. (e) Ceiling-level exhausts; source
patient bed 6, facing towards bed 5; exhalation velocity 0.12 m/s. (f) Ceiling-level exhausts; source patient bed 6, facing towards bed 5;
exhalation velocity 2.00 m/s

pollutants. Hence, we recommend the use of a down-


Acknowledgements
ward ventilation supply and ceiling-level exhaust for
future isolation room design, subject to a possible field The work described was supported by the Research
study with epidemiological data. In a separate study, Grants Council of the Hong Kong SAR Government
the same conclusion is reached when the respiratory (Project No. HKU 7150/06E), Research Grants from
droplets are studied, including the effect of evapora- National Nature and Science Foundation of China
tion. Additionally, surface deposition as the major (NSFC) (Project No. 50808038) and Research Grants
removal mechanism of particles reveals the significance from Jiangsu Fundamental Research Project (Project
of regular surface cleaning and disinfection, and No. BK2009289). The authors thank Dr Sun Hequan
provides good evidence for maintaining isolation room for providing guidance in using the particle image
surface hygiene. processing software.

References
AIA (2001) Guidelines for Design and Con- Brohus, H. (1997) Personal Exposure to Centers for Disease Control and
struction of Hospital and Health Care Contaminant Sources in Ventilated Rooms, Prevention.
Facilities, Washington, D.C., American PhD Thesis, Aalborg University, Chao, C.Y.H. and Wan, M.P. (2006) A
Institute of Architects. Denmark. study of the dispersion of expiratory
ASHRAE (2003) HVAC Design Manual for CDC (1994) Guidelines for preventing trans- aerosols in unidirectional downward and
Hospitals and Clinics, Atlanta, Ga., mission of Mycobacterium tuberculosis in ceiling-return type airflows using a
American Society of Heating Refrigerat- health-care settings, Morb. Mortal. Wkly multiphase approach, Indoor Air, 16,
ing and Air-Conditioning Engineers Inc. Rep., 43 (RR-13):1–132, Centers for 296–312.
Bouilly, J., Limam, K., Béghein, C. and Disease Control and Prevention. Chao, C.Y.H., Wan, M.P. and To, G.N.S.
Allard, F. (2005) Effect of ventilation CDC (2005) Guidelines for preventing the (2008) Transport and removal of
strategies on particle decay rates indoors: transmission of Mycobacterium tubercu- expiratory droplets in hospital ward
an experimental and modelling study, losis in health-care facilities, Morb. environment, Aerosol Sci. Technol., 42,
Atmos. Environ., 39, 4885–4892. Mortal. Wkly Rep., 54 (RR-17):1–142, 377–394.

296
Airborne infection isolation room ventilation

Ferziger, J.H. and Peric, M. (2002) Compu- Nazaroff, W.W., Nicas, M. and Miller, S.L. analysis of suspended sediment image,
tational Methods for Fluid Dynamics, (1998) Framework for evaluating mea- China Particuo., 3, 204–207.
Berlin, New York, Springer. sures to control nosocomial tuberculosis Tung, Y.C., Hu, S.C., Tsai, T.I. and Chang,
Gao, N.P. and Niu, J.L. (2007) Modeling transmission, Indoor Air, 8, 205–218. I.L. (2009) An experimental study on
particle dispersion and deposition in Qian, H., Li, Y., Nielsen, P.V., Hyldgaard, ventilation efficiency of isolation room,
indoor environments, Atmos. Environ., C.E., Wong, T.W. and Chwang, A.T.Y. Build. Environ., 44, 271–279.
41, 3862–3876. (2006) Dispersion of exhaled droplet WHO (2003) Summary of Probable SARS
Kao, P.H. and Yang, R.J. (2006) Virus dif- nuclei in a two-bed hospital ward with Cases With Onset of Illness From 1
fusion in isolation rooms, J. Hosp. Infect., three different ventilation systems, Indoor November 2002 to 31 July 2003, Geneva,
62, 338–345. Air, 16, 111–128(Correction, 16 (3): 256- World Health Organization.
Lai, A.C. (2002) Particle deposition indoors: 256; 2006). WHO (2007) Infection Prevention and Control
a review, Indoor Air, 12, 211–214. Qian, H., Li, Y., Nielsen, P.V., Hyldgaard, of Epidemic- and Pandemic-prone Acute
Lai, A.C.K. and Cheng, Y.C. (2007) Study of C.E. and Wong, T.W. (2008) Dispersion Respiratory Diseases in Health Care –
expiratory droplet dispersion and trans- of exhalation pollutants in a two-bed WHO Interim Guidelines, Geneva, World
port using a new Eulerian modeling hospital ward with a downward ventila- Health Organization.
approach, Atmos. Environ., 41, 7473–7484. tion system, Build. Environ., 43, 344–354. Zhao, B., Zhang, Y., Li, X.T., Yang, X.D.
Li, Y., Ching, W.H., Qian, H., Yuen, P.L., Saravia, S.A., Raynor, P.C. and Streifel, A.J. and Huang, D.T. (2004) Comparison of
Seto, W.H., Kwan, J.K., Leung, J.K.C., (2007) A performance assessment of air- indoor aerosol particle concentration and
Leung, M. and Yu, S.C.T. (2007) An borne infection isolation rooms, Am. J. deposition in different ventilated rooms
evaluation of the ventilation performance Infect. Control, 35, 324–331. by numerical method, Build. Environ., 39,
of new SARS isolation wards in nine Shih, Y.C., Chiu, C.C. and Wang, O. (2007) 1–8.
hospitals in Hong Kong, Indoor Built Dynamic airflow simulation within an Zhu, S.W., Kato, S. and Yang, J.H. (2006)
Environ., 16, 400–410. isolation room, Build. Environ., 42, 3194– Study on transport characteristics of sal-
Nazaroff, W.W. (2004) Indoor particle 3209. iva droplets produced by coughing in a
dynamics, Indoor Air, 14(Suppl. 7), 175– Sun, H., Yu, L., Shen, Y., Yu, D. and Zhu, calm indoor environment, Build. Environ.,
183. G. (2005) Application of CDF(2,2) to 41, 1691–1702.

297