The document discusses guidelines for designing health facilities to promote infection control through proper ventilation and indoor air quality. It emphasizes the importance of passive ventilation strategies like open windows, as studies have shown closed environments concentrate more pathogens. Design approaches should consider the local climate and prioritize natural ventilation over fully mechanical systems where possible. Material selection, surface finishes, and planning layouts also impact infection control and need to balance hygiene, acoustics, and antimicrobial resistance. An integrated, multidisciplinary approach is advocated to create sustainable, healthy hospital buildings.

1. Health Facilities Design
for
Infection Control
Tobias van Reenen and Peta de Jager
16 August 2013, Cape Town

2. “It may seem a strange
principle to annunciate as the
very first requirement in a
hospital is that it do the sick
no harm.”
Florence Nightingale

3. South African Constitution
Everyone is equal before the law and has the right to equal
protection and benefit of the law.
Environmental rights in the Bill of Rights include the right to
an environment that supports health and wellbeing. It also
requires legislation to be developed to ensure that the
environment is protected and that development that does
occur is both sustainable, and justifiable:

4. Environment
Everyone has the right
a. to an environment that is not harmful to their health or
well-being; and
b. to have the environment protected, for the benefit of
present and future generations, through reasonable
legislative and other measures that
i. prevent pollution and ecological degradation;
ii. promote conservation; and
iii. secure ecologically sustainable development and use of
natural resources while promoting justifiable economic
and social development

5. IUSS Sustainability Guidelines
Environmental objectives
• Environmental objectives
• Energy: The building is energy efficient and uses renewable energy
• Water: The building minimises the consumption of mains potable
water.
• Waste: The building minimizes emissions and waste directed to
landfill
• Materials: Construction impacts of building are minimized
• Biodiversity: The building supports biodiversity
Mirebalais Hospital, Haiti – Nicholas Clark Architects
Ltd.

6. Healthy, green health building:
Economic objectives
• Economic objectives
• Transport: The building supports energy efficient transportation
• Resource Use: The building makes efficient use of resources
• Management: The building is managed to support sustainability
• Local Economy: The building supports the local economy
• Products and Services: The building supports use of more
sustainable products and service

7. Healthy, green health building:
Social objectives
• Social objectives
• Access
• Health
• Education
• Inclusion
• Social Cohesion

8. The ―Florence Nightingale‖ Approach
• Florence Nightingale wrote over
150 years ago that open
windows were the hallmark
of a healthy hospital ward1
• Indoor microbial environments
consist largely of human
associated bacteria and
pathogens.
• Outdoor microbial environments
have a profile that look like plants
and soil and are comparatively
harmless
1 Nightigalen F. (1859). Notes on Nursing. D. Appleton: London.
2Kembel, S. et al (2012)

9. • A 2012 study by University of
Oregon proved that while clinics
with open windows had more
pathogens, closed window
environments were more harmful2
• Ventilation method accounts for a
greater variance in airborne
bacterial pathogenicity than
ventilation rates alone2
2Kembel, S. W., Jones, … Green, J. L. (2012). Architectural design influences the diversity and structure of the built
environment microbiome. The ISME Journal, 6(8), 1469–79.
Indoor air quality
Photo: Etienne du Plessis
South Africa’s oldest
hospital:
Somerset
Hospital. Circa 1890

10. • TB leading cause of mortality
in South Africa4
• South Africa has the 3rd
highest incidence of TB cases
in the world3
• 5th highest number of drug-
resistant TB cases in the
world3
• 60% – 80% of all TB cases co-
infected with HIV5,6
3 WHO. (2011). 4 Statistics South Africa. (2011). 5 WHO. (2009). 6 Gandhi et al. (2006).
Epidemiology
North Carolina State
Sanatorium, men’s ward, 1926

11. • TB is spread by the airborne transmission route
• Consider the occupational risks7,8
7 Joshi, R., Reingold A. L., Menzies, D., Pai, M. (2006). Tuberculosis among health-care workers in low- and
middle-income countries: a systematic review. PlosMed 3(12);e494 (after Dr Paul Jensen)
8 Menzies, D., Joshi, R., Pai, M. (2006). Risk of tuberculosis infection and disease associated with work in
healthcare settings. Int J Tuberc Lung Dis 11(6): 593-605 (after Dr Paul Jensen)
An issue of indoor air quality…
Work location Incidence
(worker relative to general population)
Outpatient facilities 4.2 – 11.6
General medical wards 3.9 – 36.6
Inpatient facilities 14.6 – 99.0
Emergency rooms 26.6 – 31.9
Laboratories 42.5 – 135.3

12. Routes of infection
Adjacent
Areas
Instruments
Room Air
Floor
Personnel
Mouth HandsBody
Adapted from Memarzadeh, 2003
Patient
Susceptible Infection Site
Building
Services
Vector
s

13. Sekgoma Memorial Hospital, Serowe

14. Sekgoma Memorial Hospital, Serowe

15. Occupants/equipment
NOT ADAPTABLE or
tolerant of
indoor conditions
Occupants/equipment
ADAPTABLE or
tolerant of
indoor conditions
Ventilation design philosophy
• Hierarchy of Design Solutions
Fully mechanical
ventilation
Hybrid systems with
climatic adaptability
Fully passive
ventilation
Occupiedarea

16. • Planning for passive ventilation, heating and cooling
• Layout and zoning for passive design responses
Specialist areas
(ICU, surgery)
Intermediate
areas
(Trauma, food
services)
General areas
(Wards, waiting
and public areas)
Ventilation design philosophy

17. • National Building Regulations
and Building Standards Act
(Act 103 of 1977)
• SANS 10400 XA
• SANS 10400 O
• SANS 204 (Incorporated)
Standards and
regulations

18. • Ventilation SANS10400-0
• Table 2 all but prohibits
recirculation in health
care buildings.
• Table 2 Excludes
l/s/person calculations
for health care buildings
Standards and
regulations

19. WHY RECIRCULATE?
• Consider a conditioned space which is maintained at 22C:
• Cooling plant energy cost is reduced by between 80% and
95%:
Advantage:
• Lower energy and operating cost at the cooling plant.
• Smaller cooling plant and lower capital cost
Disadvantage:
• More difficult to maintain indoor air quality
Source: Dr J Dirker UP
Standards and
regulations

20. Adaptive approach
-Increased air movement (-2°C)
• Precise relationships between increased air speed comfort have
not been established.
• Provide ability to control air speeds to < 0.8m/s
• >0.2m/s can be considered draughty with HVAC
Thermal comfort
ASHRAE55Figure5.2.3
Airspeedrequiredtooffsetincreased
temperature

21. Climatic classification (CSIR, 2010)

22. Climatic classification
Description Köppen-Geiger
Class.
Area in
km²
Percentage
(%)
Equatorial climates
(0.2% of area) Aw 2296.00 0.20
Arid climates
(70.89% of area)
Bsh 192269.00 16.59
Bsk 275927.00 23.81
Bwh 188784.00 16.29
Bwk 164629.00 14.20
Warm temperate
climates (28.91% of
area)
Cfa 42918.00 3.70
Cfb 93405.00 8.06
Cfc 84.00 0.01
Csa 5120.00 0.44
Csb 18395.00 1.59
Cwa 31162.00 2.69
Cwb 140405.00 12.11
Cwc 3564.00 0.31
Total 1158958 100.00

23. Responsive design approaches

24. Bongani MDR TB Hospital, Mpumalanga
THERMALCOMFORT
Design for climate
Skills of a multi-disciplinary team: but not business-as-usual

25. Surfaces and materials
• Smooth, hard, impervious surfaces
create best hygienic environments
• Smooth, hard, impervious surfaces
create the worst acoustic
environments
http://designtoheal.org/case-
studies/butaro-district-hospital/

26. Antimicrobial resistance
http://123sonography.com/blog/the-ignorant

27. Surfaces and materials
• Vinyl and tiled finishes create
cavities behind which cannot be
cleaned when bonding system fails
• Paint wall finishes recommended
above vinyl
• Design/select fixtures which do not
hinder cleaning

28. Surfaces and materials
• Consider materials’ environmental
lifecycle
• Origin
• Durability
• Toxicity
• Recycling
• Disposal
• Consider vinyl if:
• BRE A+ Rating = 100%
recyclable
• Pass VOC emissions test
• Consider toxicity of adhesives
http://designtoheal.org/case-
studies/butaro-district-hospital/

29. Planning
IUSS Central Sterile Service
Department

30. Engineering Services

31. Healthy, green health building:
A 3–pronged approach
• Consumption and emissions
• Benchmarks, targets, minima
• Monitoring and progressive
improvement
• Rework professional duties,
interdisciplinary relationships and
incentives
• Life cycle analysis
• Components and materials
• Whole building
• Appreciate sector-specific
challenges

32. 32
2013/08/27
QUESTIONS?

33. Resources & References
Bibby, C., & Hodgson, M. (2013). Prediction study of factors affecting speech privacy
between rooms and the effect of ventilation openings. Applied Acoustics, 74(4),
585–590.
ASHRAE 55-2004; Thermal environmental conditions for human occupant, 2004.
ISO 7730:2005 Ergonomics of the thermal environment -- Analytical determination
and interpretation of thermal comfort using calculation of the PMV and PPD indices
and local thermal comfort criteria
CIBSE AM10; Irving, S., Ford, B., & Etheridge, D. (David W. . (2005). Natural
ventilation in non-domestic buildings.
CIBSE. (2000). CIBSE Applications Manual AM13: Mixed mode ventilation.
CCIBSE. CIBSE Knowledge Series KS17— Indoor air quality and ventilation.
Nightingale, F. (1859). Notes on Nursing. D. Appleton: London.
Kembel, S. W., Jones, … Green, J. L. (2012). Architectural design influences the
diversity and structure of the built environment microbiome. The ISME journal,
6(8), 1469–79

34. Resources & References
• CDC
• CSIR
• FIDSSA –Federation of Infectious Diseases of South Africa
• ICAN –Infection Control African Network
• MRC - Medical Research Council
• National Department of Health – www.iussonline.co.za
• NHLS – National Health Laboratory Services
• NIOH – National Institute of Occupational Health
• NICD – National Institute of Communicable Diseases
• SAFHE – South African Federation of Hospital Engineering
• WHO