Ventilation procedures to minimize the airborne transmission of viruses in classrooms

Viral infection transmission and indoor air quality: A systematic review

Respiratory disease transmission in indoor environments presents persistent challenges for health authorities, as exemplified by the recent COVID-19 pandemic. This underscores the urgent necessity to investigate the dynamics of viral infection transmission within indoor environments. This systematic review delves into the methodologies of respiratory infection transmission in indoor settings and explores how the quality of indoor air (IAQ) can be controlled to alleviate this risk while considering the imperative of sustainability. Among the 2722 articles reviewed, 178 were retained based on their focus on respiratory viral infection transmission and IAQ. Fifty eight articles delved into SARS-CoV-2 transmission, 21 papers evaluated IAQ in contexts of other pandemics, 53 papers assessed IAQ during the SARS-CoV-2 pandemic, and 46 papers examined control strategies to mitigate infectious transmission. Furthermore, of the 46 papers investigating control strategies, only nine considered energy consumption. These findings highlight clear gaps in current research, such as analyzing indoor air and surface samples for specific indoor environments, oversight of indoor and outdoor parameters (e.g., temperature, relative humidity (RH), and building orientation), neglect of occupancy schedules, and the absence of considerations for energy consumption while enhancing IAQ. This study distinctly identifies the indoor environmental conditions conducive to the thriving of each respiratory virus, offering IAQ trade-offs to mitigate the risk of dominant viruses at any given time. This study argues that future research should involve digital twins in conjunction with machine learning (ML) techniques. This approach aims to enhance IAQ by analyzing the transmission patterns of various respiratory viruses while considering energy consumption.

Ventilation during COVID-19 in a school for students with intellectual and developmental disabilities (IDD)

BACKGROUND

This study examined the correlation of classroom ventilation (air exchanges per hour (ACH)) and exposure to CO2 ≥1,000 ppm with the incidence of SARS-CoV-2 over a 20-month period in a specialized school for students with intellectual and developmental disabilities (IDD). These students were at a higher risk of respiratory infection from SARS-CoV-2 due to challenges in tolerating mitigation measures (e.g. masking). One in-school measure proposed to help mitigate the risk of SARS-CoV-2 infection in schools is increased ventilation.

METHODS

We established a community-engaged research partnership between the University of Rochester and the Mary Cariola Center school for students with IDD. Ambient CO2 levels were measured in 100 school rooms, and air changes per hour (ACH) were calculated. The number of SARS-CoV-2 cases for each room was collected over 20 months.

RESULTS

97% of rooms had an estimated ACH ≤4.0, with 7% having CO2 levels ≥2,000 ppm for up to 3 hours per school day. A statistically significant correlation was found between the time that a room had CO2 levels ≥1,000 ppm and SARS-CoV-2 PCR tests normalized to room occupancy, accounting for 43% of the variance. No statistically significant correlation was found for room ACH and per-room SARS-CoV-2 cases. Rooms with ventilation systems using MERV-13 filters had lower SARS-CoV-2-positive PCR counts. These findings led to ongoing efforts to upgrade the ventilation systems in this community-engaged research project.

CONCLUSIONS

There was a statistically significant correlation between the total time of room CO2 concentrations ≥1,000 and SARS-CoV-2 cases in an IDD school. Merv-13 filters appear to decrease the incidence of SARS-CoV-2 infection. This research partnership identified areas for improving in-school ventilation.

Evaluating airflow dynamics in common vertical circulation spaces of a multi-floor apartment building for mitigating airborne infection risks: A CFD modeling study

As more people increasingly inhabit indoor spaces, the importance of interior environment design has grown significantly. The focus of this research is to assess the air flow and air change per hour (ACH) within common service vertical circulation spaces in apartment buildings, emphasizing the potential role of these spaces in mitigating airborne infections. The intricate relationships between the design parameters of these spaces and variables related to air circulation are examined. To achieve this goal, the investigation employed a simulation-based approach, utilizing computational fluid dynamics (CFD) analysis to scrutinize the prevalent design of common vertical circulation spaces. The simulation outcomes unequivocally reveal that the design of these spaces has a direct impact on air circulation patterns, often influencing suboptimal conditions. Armed with these insights, this research advocates for a reevaluation of design considerations of common service vertical circulation in forthcoming housing projects. Furthermore, this research proposes innovative design solutions and strategies aimed at enhancing natural ventilation and overall air flow within common service vertical circulation spaces while evaluating their performance.

Indoor Air Quality and COVID-19: A Scoping Review

Objectives: The COVID-19 pandemic has been a major public health concern for the past 3 years. Scientific evidence on the relationship between SARS-CoV-2 infection and indoor air quality still needs to be demonstrated. This scoping review aims to study the association between air quality indoors and COVID-19. Methods: A scoping review analyzing the association between indoor air quality and epidemiological outcomes was conducted. Papers published between 1 January 2020 and 31 October 2022 were included. Hospital settings were excluded from the study. Results: Eight relevant articles met the inclusion criteria. Indoor settings included workplaces, schools, restaurants, and public transport. Types of ventilation used to improve indoor air quality were dilution methods (opening windows) and mechanical systems with or without filtration or purifier. CO2 sensors were employed in one study. All the studies showed a positive association between indoor air quality and its improvement and epidemiological indicators. Conclusion: The findings of this scoping review indicate that indoor air quality, which can be improved with ventilation methods, may reduce the risk of developing COVID-19. Ventilation could thus be viewed as a possible effective mitigating method.

Computational analysis of an electrostatic separator design for removal of volatile organic compounds from indoor air

Concentrations of volatile organic compounds (VOCs) in air can be reduced in electrostatic separators where VOCs are ionized using ion-molecule reactions, extracted using electric fields, and eliminated in a waste flow. Embodiments for such separator technology have been explored in only a few studies, despite the possible advantage of purification without adsorbent filters. In one design, based on ionization of VOCs in positive polarity with hydrated protons as reactant ions, efficiencies for removal were measured as 30-40% . The results were fitted to a one-dimensional convective diffusion model requiring an unexpectedly high production rate of reactant ions to match both the model and data. A realistic rate of reactant ion production was used in finite element method simulations (COMSOL) and demonstrated that low removal efficiency could be attributed to non-uniform patterns of sample flow and to incomplete mixing of VOCs with reactant ions. In analysis of complex systems, such as this model, even limited computational modeling can outperform a pure analytical approach and bring insights into limiting factors or system bottlenecks.Implications: In this work, we applied modern computational methods to understand the performance of an air purifier based on electrostatics and ionized volatile organic compounds (VOCs). These were described in the publication early 2000s. The model presented was one-dimensional and did not account for the effects of flow. In our multiphysics finite element models, the efficiency and operation of the filter is better explained by the patterns of flow and flow influences on ion distributions in electric fields. In general, this work helps using and applying computational modelling to understand and improve the performance bottlenecks in air purification system designs.

Measuring Indoor Air Quality Does Not Prevent COVID-19

Boston Public Schools (BPS) closed for in-person learning in March 2020 due to COVID-19 and didn't fully reopen until the 2021-2022 school year. Due to the age of schools and absent ventilation systems, coupled with decades of disinvestment in the infrastructure, BPS entered the pandemic with serious challenges impacting the health of students and staff. These challenges were magnified by an infectious airborne virus. Instead of using this opportunity to improve ventilation systems, BPS opted to invest in an air quality monitoring system. This system only confirmed what was already known-there is poor ventilation in most school buildings. It did not lead to correction of new or long-standing problems. This failure has harmed the BPS community, which includes primarily low-income Black and Brown families. This article describes Boston's school system, its track record of inadequate attention to infrastructure, and explores pitfalls of focusing on evaluation instead of correction.

Respiratory particle emission rates from children during speaking

The number of respiratory particles emitted during different respiratory activities is one of the main parameters affecting the airborne transmission of respiratory pathogens. Information on respiratory particle emission rates is mostly available for adults (few studies have investigated adolescents and children) and generally involves a limited number of subjects. In the present paper we attempted to reduce this knowledge gap by conducting an extensive experimental campaign to measure the emission of respiratory particles of more than 400 children aged 6 to 12 years while they pronounced a phonetically balanced word list at two different voice intensity levels ("speaking" and "loudly speaking"). Respiratory particle concentrations, particle distributions, and exhaled air flow rates were measured to estimate the respiratory particle emission rate. Sound pressure levels were also simultaneously measured. We found out that median respiratory particle emission rates for speaking and loudly speaking were 26 particles s-1 (range 7.1-93 particles s-1) and 41 particles s-1 (range 10-146 particles s-1), respectively. Children sex was significant for emission rates, with higher emission rates for males during both speaking and loudly speaking. No effect of age on the emission rates was identified. Concerning particle size distributions, for both respiratory activities, a main mode at approximately 0.6 µm and a second minor mode at < 2 µm were observed, and no differences were found between males and females. This information provides important input parameters in predictive models adopted to estimate the transmission risk of airborne pathogens in indoor spaces.

Ventilation during COVID-19 in a school for students with intellectual and developmental disabilities (IDD)

Background

This study examined the correlation of classroom ventilation (air exchanges per hour (ACH)) and exposure to CO2 ≥1,000 ppm with the incidence of SARS-CoV-2 over a 20-month period in a specialized school for students with intellectual and developmental disabilities (IDD). These students were at a higher risk of respiratory infection from SARS-CoV-2 due to challenges in tolerating mitigation measures (e.g. masking). One in-school measure proposed to help mitigate the risk of SARS-CoV-2 infection in schools is increased ventilation.

Methods

We established a community-engaged research partnership between the University of Rochester and the Mary Cariola Center school for students with IDD. Ambient CO2 levels were measured in 100 school rooms, and air changes per hour (ACH) were calculated. The number of SARS-CoV-2 cases for each room was collected over 20 months.

Results

97% of rooms had an estimated ACH ≤4.0, with 7% having CO2 levels ≥2,000 ppm for up to 3 hours per school day. A statistically significant correlation was found between the time that a room had CO2 levels ≥1,000 ppm and SARS-CoV-2 PCR tests normalized to room occupancy, accounting for 43% of the variance. No statistically significant correlation was found for room ACH and per-room SARS-CoV-2 cases. Rooms with ventilation systems using MERV-13 filters had lower SARS-CoV-2-positive PCR counts. These findings led to ongoing efforts to upgrade the ventilation systems in this community-engaged research project.

Conclusions

There was a statistically significant correlation between the total time of room CO2 concentrations ≥1,000 and SARS-CoV-2 cases in an IDD school. Merv-13 filters appear to decrease the incidence of SARS-CoV-2 infection. This research partnership identified areas for improving in-school ventilation.

Air change rates and infection risk in school environments: Monitoring naturally ventilated classrooms in a northern Italian urban context

The importance of building ventilation in avoiding long-distance airborne transmission has been highlighted with the advent of the COVID-19 pandemics. Among others, school environments, in particular classrooms, present criticalities in the implementation of ventilation strategies and their impact on indoor air quality and risk of contagion. In this work, three naturally ventilated school buildings located in northern Italy have undergone monitoring at the end of the heating season. Environmental parameters, such as CO2 concentration and indoor/outdoor air temperature, have been recorded together with the window opening configurations to develop a two-fold analysis: i) the estimation of real air change rates through the transient mass balance equation method, and ii) the individual infection risk via the Wells-Riley equation. A strong statistical correlation has been found between the air change rates and the windows opening configuration by means of a window-to-volume ratio between the total opening area and the volume of the classroom, which has been used to estimate the individual infection risk. Results show that the European Standard recommendation for air renewal could be achieved by a window opening area of at least 1.5 m2, in the most prevailing Italian classrooms. Furthermore, scenarios in which the infector agent is a teacher show higher individual infection risk than those in which the infector is a student. In addition, the outcomes serve school staff as a reference to ensure adequate ventilation in classrooms and keep the risk of infection under control based on the number of the students and the volume of the classroom.

Implemented indoor airborne transmission mitigation strategies during COVID-19: a systematic review

The COVID-19 pandemic has inflicted major economic and health burdens across the world. On the other hand, the potential airborne transmission of SARS-COV-2 via air can deeply undermine the effectiveness of countermeasures against spreading the disease. Therefore, there is an intense focus to look for ways to mitigate the COVID-19 spread within various indoor settings. This work systematically reviewed articles regarding airborne transmission of SARS-COV2 in various indoor settings since the onset of the pandemic. The systematic search was performed in Scopus, Web of Science, and PubMed databases and has returned 19 original articles carefully screened with regard to inclusion and exclusion criteria. The results showed that the facilities, such as dormitories and classrooms, received the most attention followed by office buildings, healthcare facilities, residential buildings, and other potential enclosed spaces such as a metro wagon. Besides, the majority of the studies were conducted experimentally while other studies were done using computer simulations. United States (n = 5), Spain (n = 4) and China (n = 3) were the top three countries based on the number of performed research. Ventilation rate was the most influential parameter in controlling the infection spread. CO₂ was the primary reference for viral spread in the buildings. The use of natural ventilation or a combination of mechanical and natural ventilations was found to be highly effective in the studies. The current work helps in furthering research on effective interventions to improve indoor air quality and control the spread of COVID-19 and other respiratory diseases.

Supplementary information

The online version contains supplementary material available at 10.1007/s40201-023-00847-0.

CO2 concentration as an indicator of indoor ventilation performance to control airborne transmission of SARS-CoV-2

BACKGROUND

The Wells-Riley equation has been extensively used to quantify the infection risk of airborne transmission indoors. This equation is difficult to apply to actual conditions because it requires measurement of the outdoor air supply rate, which vary with time and are difficult to quantify. The method of determining the fraction of inhaled air that has been exhaled previously by someone in a building using a CO₂ concentration measurement can solve the limitations of the existing method. Using this method, the indoor CO₂ concentration threshold can be determined to keep the risk of infection below certain conditions.

METHODS

Based on the calculation of the rebreathed fraction, an appropriate mean indoor CO₂ concentration and required air exchange rate to control SARS-CoV-2 airborne transmission was calculated. The number of indoor occupants, ventilation rate, and the deposition and inactivation rates of the virus-laden aerosols were considered. The application of the proposed indoor CO₂ concentration-based infection rate control was investigated through case studies in school classrooms and restaurants.

RESULTS

In a typical school classroom environment with 20-25 occupants and an exposure time of 6-8 h, the average indoor CO₂ concentration should be kept below 700 ppm to control the risk of airborne infection indoors. The ASHRAE recommended ventilation rate is sufficient when wearing a mask in classrooms. For a typical restaurant with 50-100 occupants and an exposure time of 2-3 h, the average indoor CO₂ concentration should be kept below about 900 ppm. Residence time in the restaurant had a significant effect on the acceptable CO₂ concentration.

CONCLUSION

Given the conditions of the occupancy environment, it is possible to determine an indoor CO₂ concentration threshold, and keeping the CO₂ concentration lower than a certain threshold could help reduce the risk of COVID-19 infection.

A review on indoor airborne transmission of COVID-19– modelling and mitigation approaches

In the past few years, significant efforts have been made to investigate the transmission of COVID-19. This paper provides a review of the COVID-19 airborne transmission modeling and mitigation strategies. The simulation models here are classified into airborne transmission infectious risk models and numerical approaches for spatiotemporal airborne transmissions. Mathematical descriptions and assumptions on which these models have been based are discussed. Input data used in previous simulation studies to assess the dispersion of COVID-19 are extracted and reported. Moreover, measurements performed to study the COVID-19 airborne transmission within indoor environments are introduced to support validations for anticipated future modeling studies. Transmission mitigation strategies recommended in recent studies have been classified to include modifying occupancy and ventilation operations, using filters and air purifiers, installing ultraviolet (UV) air disinfection systems, and personal protection compliance, such as wearing masks and social distancing. The application of mitigation strategies to various building types, such as educational, office, public, residential, and hospital, is reviewed. Recommendations for future works are also discussed based on the current apparent knowledge gaps covering both modeling and mitigation approaches. Our findings show that different transmission mitigation measures were recommended for various indoor environments; however, there is no conclusive work reporting their combined effects on the level of mitigation that may be achieved. Moreover, further studies should be conducted to understand better the balance between approaches to mitigating the viral transmissions in buildings and building energy consumption.

A CFD-based framework to assess airborne infection risk in buildings

The COVID-19 pandemic has prompted huge efforts to further the scientific knowledge of indoor ventilation and its relationship to airborne infection risk. Exhaled infectious aerosols are spread and inhaled as a result of room airflow characteristics. Many calculation methods and assertions on risk assume 'well-mixed' flow conditions. However, ventilation in buildings is complex and often not showing well-mixed conditions. Ventilation guidance is typically based on the provision of generic minimum ventilation flow rates for a given space, irrespective of the effectiveness in the delivery of the supply air. Furthermore, the airflow might be heavily affected by the season, the HVAC ventilation, or the opening of windows, which would potentially generate draughts and non-uniform conditions. As a result, fresh air concentration would be variable depending upon a susceptible receptor's position in a room and, therefore, associated airborne infection risk. A computational fluid dynamics (CFD) and dynamic thermal modelling (DTM) framework is proposed to assess the influence of internal airflow characteristics on airborne infection risk. A simple metric is proposed, the hourly airborne infection rate (HAI) which can easily help designers to stress-test the ventilation within a building under several conditions. A case study is presented, and the results clearly demonstrate the importance of understanding detailed indoor airflow characteristics and associated concentration patterns in order to provide detailed design guidance, e.g. occupancy, supply air diffusers and furniture layouts, to reduce airborne infection risk.

Respiratory aerosol particle emission and simulated infection risk is greater during indoor endurance than resistance exercise

Pathogens such as severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2), influenza, and rhinoviruses are transmitted by airborne aerosol respiratory particles that are exhaled by infectious subjects. We have previously reported that the emission of aerosol particles increases on average 132-fold from rest to maximal endurance exercise. The aims of this study are to first measure aerosol particle emission during an isokinetic resistance exercise at 80% of the maximal voluntary contraction until exhaustion, second to compare aerosol particle emission during a typical spinning class session versus a three-set resistance training session. Finally, we then used this data to calculate the risk of infection during endurance and resistance exercise sessions with different mitigation strategies. During a set of isokinetic resistance exercise, aerosol particle emission increased 10-fold from 5,400 ± 1,200 particles/min at rest to 59,000 ± 69,900 particles/min during a set of resistance exercise. We found that aerosol particle emission per minute is on average 4.9-times lower during a resistance training session than during a spinning class. Using this data, we determined that the simulated infection risk increase during an endurance exercise session was sixfold higher than during a resistance exercise session when assuming one infected participant in the class. Collectively, this data helps to select mitigation measures for indoor resistance and endurance exercise classes at times where the risk of aerosol-transmitted infectious disease with severe outcomes is high.

Systematic Review of the Key Factors Influencing the Indoor Airborne Spread of SARS-CoV-2

The COVID-19 pandemic due to the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has been plaguing the world since late 2019/early 2020 and has changed the way we function as a society, halting both economic and social activities worldwide. Classrooms, offices, restaurants, public transport, and other enclosed spaces that typically gather large groups of people indoors, and are considered focal points for the spread of the virus. For society to be able to go “back to normal”, it is crucial to keep these places open and functioning. An understanding of the transmission modes occurring in these contexts is essential to set up effective infection control strategies. This understanding was made using a systematic review, according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement (PRISMA) 2020 guidelines. We analyze the different parameters influencing airborne transmission indoors, the mathematical models proposed to understand it, and discuss how we can act on these parameters. Methods to judge infection risks through the analysis of the indoor air quality are described. Various mitigation measures are listed, and their efficiency, feasibility, and acceptability are ranked by a panel of experts in the field. Thus, effective ventilation procedures controlled by CO2-monitoring, continued mask wearing, and a strategic control of room occupancy, among other measures, are put forth to enable a safe return to these essential places.

The Influence of Ventilation Measures on the Airborne Risk of Infection in Schools: A Scoping Review

OBJECTIVES

To review the risk of airborne infections in schools and evaluate the effect of intervention measures reported in field studies.

BACKGROUND

Schools are part of a country's critical infrastructure. Good infection prevention measures are essential for reducing the risk of infection in schools as much as possible, since these are places where many individuals spend a great deal of time together every weekday in a small area where airborne pathogens can spread quickly. Appropriate ventilation can reduce the indoor concentration of airborne pathogens and reduce the risk of infection.

METHODS

A systematic search of the literature was conducted in the databases Embase, MEDLINE, and ScienceDirect using keywords such as school, classroom, ventilation, carbon dioxide (CO2) concentration, SARS-CoV-2, and airborne transmission. The primary endpoint of the studies selected was the risk of airborne infection or CO2 concentration as a surrogate parameter. Studies were grouped according to the study type.

RESULTS

We identified 30 studies that met the inclusion criteria, six of them intervention studies. When specific ventilation strategies were lacking in schools being investigated, CO2 concentrations were often above the recommended maximum values. Improving ventilation lowered the CO2 concentration, resulting in a lower risk of airborne infections.

CONCLUSIONS

The ventilation in many schools is not adequate to guarantee good indoor air quality. Ventilation is an important measure for reducing the risk of airborne infections in schools. The most important effect is to reduce the time of residence of pathogens in the classrooms.

New dose-response model and SARS-CoV-2 quanta emission rates for calculating the long-range airborne infection risk

Predictive models for airborne infection risk have been extensively used during the pandemic, but there is yet still no consensus on a common approach, which may create misinterpretation of results among public health experts and engineers designing building ventilation. In this study we applied the latest data on viral load, aerosol droplet sizes and removal mechanisms to improve the Wells Riley model by introducing the following novelties i) a new model to calculate the total volume of respiratory fluid exhaled per unit time ii) developing a novel viral dose-based generation rate model for dehydrated droplets after expiration iii) deriving a novel quanta-RNA relationship for various strains of SARS-CoV-2 iv) proposing a method to account for the incomplete mixing conditions. These new approaches considerably changed previous estimates and allowed to determine more accurate average quanta emission rates including omicron variant. These quanta values for the original strain of 0.13 and 3.8 quanta/h for breathing and speaking and the virus variant multipliers may be used for simple hand calculations of probability of infection or with developed model operating with six size ranges of aerosol droplets to calculate the effect of ventilation and other removal mechanisms. The model developed is made available as an open-source tool.

[Promoting Better Indoor Air Quality in Portugal for Disease Prevention and Control]

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Increasing ventilation reduces SARS-CoV-2 airborne transmission in schools: A retrospective cohort study in Italy's Marche region

Introduction

While increasing the ventilation rate is an important measure to remove inhalable virus-laden respiratory particles and lower the risk of infection, direct validation in schools with population-based studies is far from definitive.

Methods

We investigated the strength of association between ventilation and SARS-CoV-2 transmission reported among the students of Italy's Marche region in more than 10,000 classrooms, of which 316 were equipped with mechanical ventilation. We used ordinary and logistic regression models to explore the relative risk associated with the exposure of students in classrooms.

Results and discussion

For classrooms equipped with mechanical ventilation systems, the relative risk of infection of students decreased at least by 74% compared with a classroom with only natural ventilation, reaching values of at least 80% for ventilation rates >10 L s^-1 student^-1. From the regression analysis we obtained a relative risk reduction in the range 12%15% for each additional unit of ventilation rate per person. The results also allowed to validate a recently developed predictive theoretical approach able to estimate the SARS-CoV-2 risk of infection of susceptible individuals via the airborne transmission route. We need mechanical ventilation systems to protect students in classrooms from airborne transmission; the protection is greater if ventilation rates higher than the rate needed to ensure indoor air quality (>10 L s^-1 student^-1) are adopted. The excellent agreement between the results from the retrospective cohort study and the outcome of the predictive theoretical approach makes it possible to assess the risk of airborne transmission for any indoor environment.

Targeted reduction of airborne viral transmission risk in long-term residential aged care

COVID-19 has demonstrated the devastating consequences of the rapid spread of an airborne virus in residential aged care. We report the use of CO2-based ventilation assessment to empirically identify potential 'super-spreader' zones within an aged care facility, and determine the efficacy of rapidly implemented, inexpensive, risk reduction measures.

Challenges and Actions of IAQ under COVID-19: A Survey of Taiwanese People's Perception of Epidemic Prevention and Indoor Places Certification

COVID-19 is still spreading around the world, and the pandemic has awakened the public's attention to environmental cleanliness. This article used an online survey for people living in Taiwan, and a total of 1206 valid questionnaires were collected in October 2021. According to the survey results of Taiwanese people's awareness of and needs for epidemic prevention and IAQ, 94.4% of the respondents agreed that maintaining IAQ during the COVID-19 pandemic is very important for prevention. In addition, 95.4% of them also pointed out that the "Clean and Safe" mark certification should be promoted in public places. Finally, this article also uses hierarchical regression to analyze public perceptions of seven indoor places, including elevators, restaurants, dwellings, offices, gyms, kindergartens, and long-term care centers. The results found that: (1) from the perspective of epidemic prevention, improving IAQ through ventilation strategies could prevent the spread of the COVID-19 pandemic, and (2) from the perspective of promotion certification, the elevators, restaurants and offices could establish strengthened IAQ, dwellings, gyms and long-term care centers should emphasize the display of IAQ information in entrances and exits, and kindergartens should focus on increasing safety and reducing infection.

Occupancy-aided ventilation for airborne infection risk control: Continuously or intermittently reduced occupancies?

Ventilation is an important engineering measure to control the airborne infection risk of acute respiratory diseases, e.g., Corona Virus Disease 2019 (COVID-19). Occupancy-aided ventilation methods can effectively improve the airborne infection risk control performance with a sacrifice of decreasing working productivity because of the reduced occupancy. This study evaluates the effectiveness of two occupancy-aided ventilation methods, i.e., the continuously reduced occupancy method and the intermittently reduced occupancy method. The continuously reduced occupancy method is determined by the steady equation of the mass conservation law of the indoor contaminant, and the intermittently reduced occupancy method is determined by a genetic algorithm-based optimization. A two-scenarios-based evaluation framework is developed, i.e., one with targeted airborne infection risk control performance (indicated by the mean rebreathed fraction) and the other with targeted working productivity (indicated by the accumulated occupancy). The results show that the improvement in the airborne infection risk control performance linearly and quadratically increases with the reduction in the working productivity for the continuously reduced occupancy method and the intermittently reduced occupancy method respectively. At a given targeted airborne infection risk control performance, the intermittently reduced occupancy method outperforms the continuously reduced occupancy method by improving the working productivity by up to 92%. At a given targeted working productivity, the intermittently reduced occupancy method outperforms the continuously reduced occupancy method by improving the airborne infection risk control performance by up to 38%.

Assessment of SARS-CoV-2 airborne infection transmission risk in public buses

Public transport environments are thought to play a key role in the spread of SARS-CoV-2 worldwide. Indeed, high crowding indexes (i.e. high numbers of people relative to the vehicle size), inadequate clean air supply, and frequent extended exposure durations make transport environments potential hotspots for transmission of respiratory infections. During the COVID-19 pandemic, generic mitigation measures (e.g. physical distancing) have been applied without also considering the airborne transmission route. This is due to the lack of quantified data about airborne contagion risk in transport environments.

In this study, we apply a novel combination of close proximity and room-scale risk assessment approaches for people sharing public transport environments to predict their contagion risk due to SARS-CoV-2 respiratory infection. In particular, the individual infection risk of susceptible subjects and the transmissibility of SARS-CoV-2 (expressed through the reproduction number) are evaluated for two types of buses, differing in terms of exposure time and crowding index: urban and long-distance buses. Infection risk and reproduction number are calculated for different scenarios as a function of the ventilation rates (both measured and estimated according to standards), crowding indexes, and travel times. The results show that for urban buses, the close proximity contribution significantly affects the maximum occupancy to maintain a reproductive number of <1. In particular, full occupancy of the bus would be permitted only for an infected subject breathing, whereas for an infected subject speaking, masking would be required. For long-distance buses, full occupancy of the bus can be maintained only if specific mitigation solutions are simultaneously applied. For example, for an infected person speaking for 1 h, appropriate filtration of the recirculated air and simultaneous use of FFP2 masks would permit full occupancy of the bus for a period of almost 8 h. Otherwise, a high percentage of immunized persons (>80%) would be needed.

The airborne contagiousness of respiratory viruses: A comparative analysis and implications for mitigation

The infectious emission rate is a fundamental input parameter for airborne transmission risk assessment, but data are limited due to reliance on estimates from chance superspreading events. This study assesses the strength of a predictive estimation approach developed by the authors for SARS-CoV-2 and uses novel estimates to compare the contagiousness of respiratory pathogens. We applied the approach to SARS-CoV-1, SARS-CoV-2, MERS, measles virus, adenovirus, rhinovirus, coxsackievirus, seasonal influenza virus and Mycobacterium tuberculosis (TB) and compared quanta emission rate (ERq) estimates to literature values. We calculated infection risk in a prototypical classroom and barracks to assess the relative ability of ventilation to mitigate airborne transmission. Our median standing and speaking ERq estimate for SARS-CoV-2 (2.7 quanta h-1) is similar to active, untreated TB (3.1 quanta h-1), higher than seasonal influenza (0.17 quanta h-1), and lower than measles virus (15 quanta h-1). We calculated event reproduction numbers above 1 for SARS-CoV-2, measles virus, and untreated TB in both the classroom and barracks for an activity level of standing and speaking at low, medium and high ventilation rates of 2.3, 6.6 and 14 L per second per person (L s-1 p-1), respectively. Our predictive ERq estimates are consistent with the range of values reported over decades of research. In congregate settings, current ventilation standards are unlikely to control the spread of viruses with upper quartile ERq values above 10 quanta h-1, such as SARS-CoV-2, indicating the need for additional control measures.

New French guidelines to adapt the "Isolate/Detect/Trace" strategy for COVID-19 adult peoples or contacts considering the exponential spread of Omicron variant

INTRODUCTION

The objectives were to elaborate new recommendations for the French Government taking into account the new epidemiological situation due to Omicron variant of SARS-CoV-2 virus and to maintain essential functions of the State through socioeconomic and health life.

METHOD

Two self-decision matrix were built for isolation (cases) and quarantine (contacts) and for citizen testing, respectively. The recommendations included in the two matrix were validated internally by experts and scientists from the scientist literature.

RESULTS

A strategic breakdown into five phases corresponding to the possible phases of Omicron variants spread was built. Exceptional and transitory derogation for essential activities was proposed in fully vaccinated professionals. Suspension of quarantine period for fully vaccinated contacts and professionals was proposed with routine self-testing program.

CONCLUSION

These new HCSP guidelines aims to preserve public health as a whole and to minimize the socioeconomic and health consequences linked to the emergence of the Omicron variant by making trade-offs/adaptations in dependent scientist contexts.

PATIENT OR PUBLIC CONTRIBUTION

HCSP scientists and experts were in charge of drafting the recommendations and promoting them to the Government for their application by regulatory decree voted by law.

A multi-layered strategy for COVID-19 infection prophylaxis in schools: A review of the evidence for masks, distancing, and ventilation

Implications for the academic and interpersonal development of children and adolescents underpin a global political consensus to maintain in-classroom teaching during the ongoing COVID-19 pandemic. In support of this aim, the WHO and UNICEF have called for schools around the globe to be made safer from the risk of COVID-19 transmission. Detailed guidance is needed on how this goal can be successfully implemented in a wide variety of educational settings in order to effectively mitigate impacts on the health of students, staff, their families, and society. This review provides a comprehensive synthesis of current scientific evidence and emerging standards in relation to the use of layered prevention strategies (involving masks, distancing, and ventilation), setting out the basis for their implementation in the school environment. In the presence of increasingly infectious SARS-Cov-2 variants, in-classroom teaching can only be safely maintained through a layered strategy combining multiple protective measures. The precise measures that are needed at any point in time depend upon a number of dynamic factors, including the specific threat-level posed by the circulating variant, the level of community infection, and the political acceptability of the resultant risk. By consistently implementing appropriate prophylaxis measures, evidence shows that the risk of infection from in-classroom teaching can be dramatically reduced. Current studies indicate that wearing high-quality masks and regular testing are amongst the most important measures in preventing infection transmission; whilst effective natural and mechanical ventilation systems have been shown to reduce infection risks in classrooms by over 80%.

A review of strategies and their effectiveness in reducing indoor airborne transmission and improving indoor air quality

Airborne transmission arises through the inhalation of aerosol droplets exhaled by an infected person and is now thought to be the primary transmission route of COVID-19. Thus, maintaining adequate indoor air quality levels is vital in mitigating the spread of the airborne virus. The cause-and-effect flow of various agents involved in airborne transmission of viruses has been investigated through a systematic literature review. It has been identified that the airborne virus can stay infectious in the air for hours, and pollutants such as particulate matter (PM10, PM2.5), Nitrogen dioxide (NO2), Sulphur dioxide (SO2), Carbon monoxide (CO), Ozone (O3), Carbon dioxide (CO2), and Total Volatile Organic Compounds (TVOCs) and other air pollutants can enhance the incidence, spread and mortality rates of viral disease. Also, environmental quality parameters such as humidity and temperature have shown considerable influence in virus transmission in indoor spaces. The measures adopted in different research studies that can curb airborne transmission of viruses for an improved Indoor Air Quality (IAQ) have been collated for their effectiveness and limitations. A diverse set of building strategies, components, and operation techniques from the recent literature pertaining to the ongoing spread of COVID-19 disease has been systematically presented to understand the current state of techniques and building systems that can minimize the viral spread in built spaces This comprehensive review will help architects, builders, realtors, and other organizations improve or design a resilient building system to deal with COVID-19 or any such pandemic in the future.

Ventilation strategies to reduce airborne transmission of viruses in classrooms: A systematic review of scientific literature

The recent pandemic due to SARS-CoV-2 has brought to light the need for strategies to mitigate contagion between human beings. Apart from hygiene measures and social distancing, air ventilation highly prevents airborne transmission within enclosed spaces. Among others, educational environments become critical in strategic planning to control the spread of pathogens and viruses amongst the population, mainly in cold conditions. In the event of a virus outbreak - such as COVID or influenza - many school classrooms still lack the means to guarantee secure and healthy environments. The present review examines school contexts that implement air ventilation strategies to reduce the risk of contagion between students. The analysed articles present past experiences that use either natural or mechanical systems assessed through mathematical models, numerical models, or full-scale experiments. For naturally ventilated classrooms, the studies highlight the importance of the architectural design of educational spaces and propose strategies for aeration control such as CO₂-based control and risk-infection control. When it comes to implementing mechanical ventilation in classrooms, different systems with different airflow patterns are assessed based on their ability to remove airborne pathogens considering parameters like the age of air and the generation of airflow streamlines. Moreover, studies report that programmed mechanical ventilation systems can reduce risk-infection during pandemic events. In addition to providing a systematic picture of scientific studies in the field, the findings of this review can be a valuable reference for school administrators and policymakers to implement the best strategies in their classroom settings towards reducing infection risks.

A novel CO2-based demand-controlled ventilation strategy to limit the spread of COVID-19 in the indoor environment

Ventilation is of critical importance to containing COVID-19 contagion in indoor environments. Keeping the ventilation rate at high level is recommended by many guidelines to dilute virus-laden respiratory particles and mitigate airborne transmission risk. However, high ventilation rate will cause high energy use. Demand-controlled ventilation is a promising technology option for controlling indoor air quality in an energy-efficient manner. This paper proposes a novel CO₂-based demand-controlled ventilation strategy to limit the spread of COVID-19 in indoor environments. First, the quantitative relationship is established between COVID-19 infection risk and average CO₂ level. Then, a sufficient condition is proposed to ensure COVID-19 event reproduction number is less than 1 under a conservative consideration of the number of infectors. Finally, a ventilation control scheme is designed to make sure the above condition can be satisfied. Case studies of different indoor environments have been conducted on a testbed of a real ventilation system to validate the effectiveness of the proposed strategy. Results show that the proposed strategy can efficiently maintain the reproduction number less than 1 to limit COVID-19 contagion while saving about 30%-50% of energy compared with the fixed ventilation scheme. The proposed strategy offers more practical values compared with existing studies: it is applicable to scenarios where there are multiple infectors, and the number of infectors varies with time; it only requires CO₂ sensors and does not require occupancy detection sensors. Since CO₂ sensors are very mature and low-cost, the proposed strategy is suitable for mass deployment in most existing ventilation systems.

Evaluation of Respiratory Particle Emission during Otorhinolaryngological Procedures in the Context of the SARS-CoV-2 Pandemic

Understanding the risk of infection by routine medical examination is important for the protection of the medical personnel. In this study we investigated respiratory particles emitted by patients during routine otolaryngologic procedures and assessed the risks for the performing physician. We developed two experimental setups to measure aerosol and droplet emission during rigid/flexible laryngoscopy, rhinoscopy, pharyngoscopy, otoscopy, sonography and patient interview for subjects with and without masks. A high-speed-camera setup was used to detect ballistic droplets (approx. > 100 µm) and an aerosol-particle-sizer was used to detect aerosol particles in the range of 0.3 µm to 10 µm. Aerosol particle counts were highly increased for coughing and slightly increased for heavy breathing in subjects without masks. The highest aerosol particle counts occurred during rigid laryngoscopy. During laryngoscopy and rhinoscopy, the examiner was exposed to increased particle emission due to close proximity to the patient’s face and provoked events such as coughing. However, even during sonography or otoscopy without a mask, aerosol particles were expelled close to the examiner. The physician’s exposure to respiratory particles can be reduced by deliberate choice of examination technique depending on medical indication and the use of appropriate equipment for the examiners and the patients (e.g., FFP2 masks for both).

Ventilation strategies and design impacts on indoor airborne transmission: A review

The COVID-19 outbreak has brought the indoor airborne transmission issue to the forefront. Although ventilation systems provide clean air and dilute indoor contaminated air, there is strong evidence that airborne transmission is the main route for contamination spread. This review paper aims to critically investigate ventilation impacts on particle spread and identify efficient ventilation strategies in controlling aerosol distribution in clinical and non-clinical environments. This article also examines influential ventilation design features (i.e., exhaust location) affecting ventilation performance in preventing aerosols spread. This paper shortlisted published documents for a review based on identification (keywords), pre-processing, screening, and eligibility of these articles. The literature review emphasizes the importance of ventilation systems' design and demonstrates all strategies (i.e., mechanical ventilation) could efficiently remove particles if appropriately designed. The study highlights the need for occupant-based ventilation systems, such as personalized ventilation instead of central systems, to reduce cross-infections. The literature underlines critical impacts of design features like ventilation rates and the number and location of exhausts and suggests designing systems considering airborne transmission. This review underpins that a higher ventilation rate should not be regarded as a sole indicator for designing ventilation systems because it cannot guarantee reducing risks. Using filtration and decontamination devices based on building functionalities and particle sizes can also increase ventilation performance. This paper suggests future research on optimizing ventilation systems, particularly in high infection risk spaces such as multi-storey hotel quarantine facilities. This review contributes to adjusting ventilation facilities to control indoor aerosol transmission.

Model and Validation Study for Optimizing Students’ Positions in Classrooms to Limit the Spread of Infectious Diseases Such as COVID

Classrooms at any educational institution have become high-risk sites for contagion during past and present pandemic periods caused by the SARS-CoV-2 (COVID-19) viral siege, given the prolonged time educators and students spend in joint activity. Among the several strategies employed by educational institutions to minimize the outbreak of contagion are regulating classroom capacity and studying the optimal spatial arrangement of students. The architectural features of each classroom, which include corridors, ventilation components, total volume, and maximum capacity, among other factors, have a direct impact on the risk of human contagion. This work is a proposal to optimize the spatial arrangement of students to minimize the risk of contagion, considering not only the distance between them, but also the different architectural features in the classrooms. The analyses conducted in the different scenarios conclude with a comparison of risk in terms of the arrangement of students that various educators would have used at different education levels in their classrooms based solely on intuitive criteria. The results indicate that in some situations, the locations chosen by educators can double the risk of infection compared to optimal arrangements.

Numerical Flow Simulation on the Virus Spread of SARS-CoV-2 Due to Airborne Transmission in a Classroom

In order to continue using highly frequented rooms such as classrooms, seminar rooms, offices, etc., any SARS-CoV-2 virus concentration that may be present must be kept low or reduced through suitable ventilation measures. In this work, computational fluid dynamics (CFD) is used to develop a virtual simulation model for calculating and analysing the viral load due to airborne transmission in indoor environments aiming to provide a temporally and spatially-resolved risk assessment with explicit relation to the infectivity of SARS-CoV-2. In this work, the first results of the model and method are presented. In particular, the work focuses on a critical area of the education infrastructure that has suffered severely from the pandemic: classrooms. In two representative classroom scenarios (teaching and examination), the duration of stay for low risk of infection is investigated at different positions in the rooms for the case that one infectious person is present. The results qualitatively agree well with a documented outbreak in an elementary school but also show, in comparisons with other published data, how sensitive the assessment of the infection risk is to the amount of virus emitted on the individual amount of virus required for infection, as well as on the supply air volume. In this regard, the developed simulation model can be used as a useful virtual assessment for a detailed seat-related overview of the risk of infection, which is a significant advantage over established analytical models.

Impacts of the COVID-19 lockdown on building energy consumption and indoor environment: A case study in Dalian, China

Restricting social distancing is an effective means of controlling the COVID-19 pandemic, resulting in a sharp drop in the utilization of commercial buildings. However, the specific changes in the operating parameters are not clear. This study aims to quantify the impact of COVID-19 lockdowns on commercial building energy consumption and the indoor environment, including correlation analysis. A large green commercial building in Dalian, China's only country to experience five lockdowns, has been chosen. We compared the performance during the lockdown to the same period last year. The study found that the first lockdown caused a maximum 63.5% drop in monthly energy consumption, and the second lockdown was 55.2%. The energy consumption per unit area in 2020 dropped by 55.4% compared with 2019. In addition, during the lockdown, the compliance rate of indoor thermal environment increased by 34.7%, and indoor air quality was 9.5%. These findings could partly explain the short-term and far-reaching effects of the lockdown on the operating parameters of large commercial buildings. Humans are likely to coexist with COVID-19 for a long time, and commercial buildings have to adapt to new energy and health demands. Effective management strategies need to be developed.

Effects of location, classroom orientation, and air change rate on potential aerosol exposure: an experimental and computational study

This study examined the dispersion of potentially infectious aerosols in classrooms by means of both a CO₂ tracer gas, and multizone contaminant transport modeling. A total of 20 tests were conducted in three different university classrooms at multiple air change rates (4.4-9.7/h), each with two different room orientations: one with the tracer gas released from six student desks toward the air return, and one with the same tracer gas released away from it. Resulting tracer concentrations were measured by 19 different monitors arrayed throughout the room. Steady-state, mean tracer gas concentrations were calculated in six instructor zones (A-F) around the periphery of the room, with the results normalized by the concentration at the return, which was assumed to be representative of the well-mixed volume of the room. Across all classrooms, zones farthest from the return (C, D) had the lowest mean normalized concentrations (0.75), while those closest to the return (A, F) had the highest (0.95). This effect was consistent across room orientations (release both toward and away from the return), and air change rates. In addition, all zones around the periphery of the room had a significantly lower concentration than those adjacent to the sources. Increasing the ventilation rate reduced tracer gas concentrations significantly. Similar trends were observed via a novel approach to CONTAM modeling of the same rooms. These results indicate that informed selection of teaching location within the classroom could reduce instructor exposure.

Link between SARS-CoV-2 emissions and airborne concentrations: Closing the gap in understanding

The airborne transmission of SARS-CoV-2 remains surprisingly controversial; indeed, health and regulatory authorities still require direct proof of this mode of transmission. To close this gap, we measured the viral load of SARS-CoV-2 of an infected subject in a hospital room (through an oral and nasopharyngeal swab), as well as the airborne SARS-CoV-2 concentration in the room resulting from the person breathing and speaking. Moreover, we simulated the same scenarios to estimate the concentration of RNA copies in the air through a novel theoretical approach and conducted a comparative analysis between experimental and theoretical results. Results showed that for an infected subject's viral load ranging between 2.4 × 10⁶ and 5.5 × 10⁶ RNA copies mL^-1, the corresponding airborne SARS-CoV-2 concentration was below the minimum detection threshold when the person was breathing, and 16.1 (expanded uncertainty of 32.8) RNA copies m^-3 when speaking. The application of the predictive approach provided concentrations metrologically compatible with the available experimental data (i.e. for speaking activity). Thus, the study presented significant evidence to close the gap in understanding airborne transmission, given that the airborne SARS-CoV-2 concentration was shown to be directly related to the SARS-CoV-2 emitted. Moreover, the theoretical analysis was shown to be able to quantitatively link the airborne concentration to the emission.

Determination of the indoor radon concentration in schools of Tenerife (Canary Islands): a comparative study

A radon survey was carried out in 18 high schools located in Tenerife Island when anti-pandemic strategies were used to reduce COVID-19 dissemination during 2021. High schools were located in radon-prone areas previously identified by the Spanish Nuclear Safety Council. Our results showed that 12 high schools presented radon activities lower than 100 Bq/m³, 5 high schools presented values in the range 100-200 Bq/m³, and only 1 high school presented radon activity concentration higher than 200 Bq/m³. Such values are below the reference level (300 Bq/m³) recommended by the Spanish legislation in the Basics Document of Health Standards (section HS6) of the Technical Building Code and the European Union directive (2013/59/EURATOM). Assuming an indoor occupancy time of about 1620 h per year, the annual dose contribution due to indoor radon exposure ranged from 0.07 to 1.18 mSv/year. Comparing such result against previous values reported in the literature on the island of Tenerife, we conclude that during the pandemic situation the indoor radon concentration (median valued) was reduced from 130.9 (2007) to 73.5 (2021) Bq/m³. Finally, continuous indoor radon concentration measurements were obtained to study short-time fluctuations (intra-day changes) under different ventilation conditions.

Risk of SARS-CoV-2 in a car cabin assessed through 3D CFD simulations

In this study, the risk of infection from SARS-CoV-2 Delta variant of passengers sharing a car cabin with an infected subject for a 30-min journey is estimated through an integrated approach combining a recently developed predictive emission-to-risk approach and a validated CFD numerical model numerically solved using the open-source OpenFOAM software. Different scenarios were investigated to evaluate the effect of the infected subject position within the car cabin, the airflow rate of the HVAC system, the HVAC ventilation mode, and the expiratory activity (breathing vs. speaking). The numerical simulations here performed reveal that the risk of infection is strongly influenced by several key parameters: As an example, under the same ventilation mode and emitting scenario, the risk of infection ranges from zero to roughly 50% as a function of the HVAC flow rate. The results obtained also demonstrate that (i) simplified zero-dimensional approaches limit proper evaluation of the risk in such confined spaces, conversely, (ii) CFD approaches are needed to investigate the complex fluid dynamics in similar indoor environments, and, thus, (iii) the risk of infection in indoor environments characterized by fixed seats can be in principle controlled by properly designing the flow patterns of the environment.

Effects of face masks and ventilation on the risk of SARS-CoV-2 respiratory transmission in public toilets: a quantitative microbial risk assessment

Public toilets may increase the risk of COVID-19 infection via airborne transmission; however, related research is limited. We aimed to estimate SARS-CoV-2 infection risk through respiratory transmission using a quantitative microbial risk assessment framework by retrieving SARS-CoV-2 concentrations from the swab tests of 251 Thai patients. Three virus-generating scenarios were investigated: an infector breathing, breathing with a cough, and breathing with a sneeze. The infection risk (95th percentile) was as high as 10^-1 with breathing and increased to 1 with a cough or a sneeze. No significant gender differences for toilet users (receptors) were noted. The highest risk scenario, namely breathing with a sneeze, was further evaluated for risk mitigation measures. Mitigation to a lower risk under 10^-3 succeeded only when the infector and the receptor both wore N95 respirators or surgical masks. Ventilation of up to 20 air changes per hour (ACH) did not decrease the risk. However, an extended waiting time of 10 min between an infector and a receptor resulted in approximately 1.0-log₁₀ further risk reduction when both wore masks with the WHO-recommended 12 ACH. The volume of expelled droplets, virus concentrations, and receptor dwell time were identified as the main contributors to transmission risk.

[Ventilation concepts in schools for the prevention of transmission of highly infectious viruses (SARS-CoV-2) by aerosols in indoor air]

Exhaled aerosol particles play an important role in the transmission of SARS-CoV‑2, particularly when many people gather indoors. This article summarises the knowledge on virus transmission in schools and practical measures to reduce aerosol-driven infections. A central preventive measure is to enhance room and building ventilation, i.e. the exchange of possibly contaminated indoor air with ambient air. Besides the concentrations of possibly infectious particles, ventilation reduces carbon dioxide concentrations, humidity and other chemical substances in indoor air as well. Irrespective of ventilation, face masks (surgical or FFP2) represent a vital part of hygiene measures. Fixed or mobile air purifiers can support these measures particularly when rooms providing only poor ventilation must be utilized. The article reflects the state of knowledge in October 2021 of the various techniques that have been shown as useful for the prevention of indirect infections. New variants of SARS-CoV‑2, the progress of the vaccination campaign in children and adolescents, and the increase in general immunity might require a re-evaluation of the prevention strategies described. The COVID-19 pandemic has revealed common deficits in room and building ventilation, not least in schools. Apart from short-term measures for the prevention of airborne infectious diseases, a long-term strategy seems advisable to alleviate the deficits encountered in schools with respect to room and building ventilation. In view of a permanent improvement of indoor air and prevention against airborne infections the fitting of schools with fixed ventilation systems - preferably including heat and moisture recovery - appears to be a sustainable social investment.