A post-occupancy study of ventilation effectiveness from high-resolution CO2 monitoring at live theatre events to mitigate airborne transmission of SARS-CoV-2

Airborne pathogen monitoring and dispersion modelling on passenger ships: A review

The COVID-19 pandemic demonstrated a profound inability of pre-pandemic passenger ship policies implemented by both ship operators and governmental authorities to detect and address newly emerging diseases. The essentiality of maritime transport puts into focus the risk of approach to address known and new emerging airborne infectious diseases that, due to increasing capacity, are likely to occur on passenger ships. In order to enhance the passenger experience, prepare shipping for pandemics like COVID-19, and improve the resilience and safety of the industry, this review critically synthesises existing literature on (1) monitoring ventilation conditions and aerosol dispersion, linking them to airborne transmission risk using airborne aerosols and ventilation performance as input parameters for computational fluid dynamics (CFD) simulations, and (2) modelling airborne disease transmission risk in controlled passenger ship environments. This review analysed 39 studies on aerosol monitoring, thermal comfort, and infection risk modelling on passenger ships (2000-2023). Additionally, 55 papers on CFD modelling of airborne pathogen dispersion were reviewed: 22 included validation, with most focused on built environments and only four specifically addressing ship environments. Two major challenges relate to the complexity and poorly characterised ventilation boundary conditions on passenger ships, and the other is the lack of suitable validation data. For this reason, ship experimental studies are required for CFD model validation. Only a handful of studies were found that have measured aerosol concentrations on board passenger ships. To the best of our knowledge, there have been no studies conducted on aerosol mass or airborne transmission sampling on board passenger ships or other types of vessels. The results of this review have the potential to create synergistic connections between experimental and modelling studies to inform, characterise and improve the development of numerical models that can accurately estimate infection risk on ships for prevention, mitigation and management of outbreaks.

Creating respiratory pathogen-free environments in healthcare and nursing-care settings: a comprehensive review

Hospital- and nursing-care-acquired infections are a growing problem worldwide, especially during epidemics, posing a significant threat to older adults in geriatric settings. Intense research during the COVID-19 pandemic highlighted the prominent role of aerosol transmission of pathogens. Aerosol particles can easily adsorb different airborne pathogens, carrying them for a long time. Understanding the dynamics of airborne pathogen transmission is essential for controlling the spread of many well-known pathogens, like the influenza virus, and emerging ones like SARS-CoV-2. Particles smaller than 50 to 100 µm remain airborne and significantly contribute to pathogen transmission. This review explores the journey of pathogen-carrying particles from formation in the airways, through airborne travel, to deposition in the lungs. The physicochemical properties of emitted particles depend on health status and emission modes, such as breathing, speaking, singing, coughing, sneezing, playing wind instruments, and medical interventions. After emission, sedimentation and evaporation primarily determine particle fate. Lung deposition of inhaled aerosol particles can be studied through in vivo, in vitro, or in silico methods. We discuss several numerical lung models, such as the Human Respiratory Tract Model, the LUng Dose Evaluation Program software (LUDEP), the Stochastic Lung Model, and the Computational Fluid Dynamics (CFD) techniques, and real-time or post-evaluation methods for detecting and characterizing these particles. Various air purification methods, particularly filtration, are reviewed for their effectiveness in healthcare settings. In the discussion, we analyze how this knowledge can help create environments with reduced PM2.5 and pathogen levels, enhancing safety in healthcare and nursing-care settings. This is particularly crucial for protecting older adults, who are more vulnerable to infections due to weaker immune systems and the higher prevalence of chronic conditions. By implementing effective airborne pathogen control measures, we can significantly improve health outcomes in geriatric settings.

Monitoring of indoor air quality at a large sailing cruise ship to assess ventilation performance and disease transmission risk

Large passenger ships are characterised as enclosed and crowded indoor spaces with frequent interactions between travellers, providing conditions that facilitate disease transmission. This study aims to provide an indoor ship CO2 dataset for inferring thermal comfort, ventilation and infectious disease transmission risk evaluation. Indoor air quality (IAQ) monitoring was conducted in nine environments (three cabins, buffet, gym, bar, restaurant, pub and theatre), on board a cruise ship voyaging across the UK and EU, with the study conducted in the framework of the EU HEALTHY SAILING project. CO2 concentrations, temperature and relative humidity (RH) were simultaneously monitored to investigate thermal characteristics and effectiveness of ventilation performance. Results show a slightly higher RH of 68.2 ± 5.3 % aboard compared to ASHRAE and ISO recommended targets, with temperature recorded at 22.3 ± 1.4 °C. Generally, good IAQ (<1000 ppm) was measured with CO2 mainly varying between 400 and 1200 ppm. The estimated air change rates (ACH) and ventilation rates (VR) implied sufficient ventilation was provided in most locations, and the theatre (VR: 86 L s-1 person-1) and cabins (VR: >20 L s-1 person-1) were highly over-ventilated. Dining areas including the pub and restaurant recorded high CO2 concentrations (>2000 ppm) potentially due to higher footfall (0.6 person m-2 and 0.4 person m-2) and limited ACH (2.3 h-1 and 0.8 h-1), indicating a potential risk of infection; these areas should be prioritised for improvement. The IAQ and probability of infection indicate there is an opportunity for energy saving by lowering hotel load for the theatre and cabins and achieving the minimum acceptable VR (10 L s-1 person-1) for occupants' comfort and disease control. Our study produced a first-time dataset from a sailing cruise ship's ventilated areas and provided evidence that can inform guidelines about the optimisation of ventilation operations in large passenger ships, contributing to respiratory health, infection control and energy efficiency aboard.

Comparing strategies for the mitigation of SARS-CoV-2 airborne infection risk in tiered auditorium venues

The COVID-19 pandemic demonstrated that reliable risk assessment of venues is still challenging and resulted in the indiscriminate closure of many venues worldwide. Therefore, this study used an experimental, numerical and analytical approach to investigate the airborne transmission risk potential of differently ventilated, sized and shaped venues. The data were used to assess the magnitude of effect of various mitigation measures and to develop recommendations. Here we show that, in general, positions in the near field of an emission source were at high risk, while the risk of infection from positions in the far field varied depending on the ventilation strategy. Occupancy, airflow rate, residence time, virus variants, activity level and face masks affected the individual and global infection risk in all venues. The global infection risk was lowest for the displacement ventilation case, making it the most effective ventilation strategy for keeping airborne transmission and the number of secondary cases low, compared to mixing or natural ventilation.

Carbon Dioxide Levels as a Key Indicator for Managing SARS-CoV-2 Airborne Transmission Risks Across 10 Indoor Scenarios

Background The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in December 2019 has led to a global pandemic through contact, droplets, and aerosolized particles. Aim This study aimed to quantify the airborne transmission risk of SARS-CoV-2 in various indoor environments. Methods Using indoor carbon dioxide (CO2) levels, we estimated the probability of airborne transmission and the basic reproduction number (R0) across 10 hypothetical indoor scenarios, including a college classroom, restaurant, classical music concert, live event, city bus, crowded train, hospital room, home, shogi match, and business meeting, using an analysis based on the modified Wells-Riley model. Results The relationship between airborne transmission rates and indoor CO2 concentrations was visualized with and without the use of masks. Without masks, at an indoor CO2 concentration of 1,000 ppm, airborne transmission rates were high in a home (100%), business meeting (100%), and hospital room (95%); however, they were moderate in a restaurant (55%), at a shogi match (22%), and at a live concert (21%); and low in a college classroom (1.7%), on a city bus (1.3%), at a classical music concert (1.0%), and on a crowded train (0.25%). In contrast, R0 was high at a live event (42.3), in a restaurant (15.9), in a home (3.00), and in a hospital room (2.86), indicating a greater risk of cluster infections. An examination of reduced airborne infection risk through surgical mask use and improved ventilation across various scenarios revealed that mask-wearing was highly effective in hospital rooms, in restaurants, at shogi matches, and in live concerts. Ventilation was particularly useful in hospital rooms, in restaurants, and at shogi matches. Discussion and conclusion In all indoor scenarios, a positive linear relationship existed between airborne transmission risk and indoor CO2 levels. The risk varied markedly across scenarios and was influenced by factors such as mask use, ventilation quality, conversation, and exposure duration. This model indicates that the risk of SARS-CoV-2 airborne transmission can be easily predicted using a CO2 meter.

Predicting the Airborne Transmission of Measles: Impact of Indoor Carbon Dioxide (CO2) Levels and Mitigation Strategies

BACKGROUND

Measles is a highly contagious cause of febrile illness typically seen in young children. It is transmitted primarily through respiratory droplets and small-particle aerosols and can remain viable in the air. Despite the availability of an effective vaccine, measles remains a major global issue, particularly in regions with low vaccination rates.

AIM

This study aimed to quantify the airborne transmission risk of the measles virus in various indoor environments.

METHODS

Using indoor carbon dioxide (CO2) levels, we estimated the probability of airborne transmission and the basic reproduction number (Ro) in four hypothetical indoor scenarios, including restaurants, mass gathering events, homes, and business meetings, based on the modified Wells-Riley model.

RESULTS

The relationship between airborne transmission rates and indoor CO2 concentrations was visualized, with and without mask usage. Without masks, at an indoor CO2 concentration of 1,000 ppm, the airborne transmission rates were high in homes (100.0%) and business meetings (100.0%) and moderate in restaurants (45.6%) and live events (30.6%). By contrast, the Ro was high in audience-participatory live events (60.9%) and restaurants (13.2%), indicating a higher risk of cluster infections.

DISCUSSION AND CONCLUSION

In all indoor environmental scenarios, a positive linear relationship was found between the risk of airborne transmission and indoor CO2 levels. The risk of airborne transmission varied significantly across scenarios, which was influenced by various parameters, such as mask usage, quality of ventilation, conversation, and exposure duration. This model suggests that the risk of airborne transmission of measles can be easily predicted using a CO2 meter.

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.

A self-controlled case series study to measure the risk of SARS-CoV-2 infection associated with attendance at sporting and cultural events: the UK Events Research Programme events

BACKGROUND

In 2021, whilst societies were emerging from major social restrictions during the SARS-CoV-2 pandemic, the UK government instigated an Events Research Programme to examine the risk of COVID-19 transmission from attendance at cultural events and explore ways to enable people to attend a range of events whilst minimising risk of transmission. We aimed to measure any impact on risk of COVID-19 transmission from attendance at events held at or close to commercially viable capacity using routinely collected data.

METHODS

Data were obtained on attendees at Phase 3 Events Research Programme events, for which some infection risk mitigation measures were in place (i.e. evidence of vaccination or a negative lateral flow test). Attendance data were linked with COVID-19 test result data from the UK Test and Trace system. Using a self-controlled case series design, we measured the within person incidence rate ratio for testing positive for COVID-19, comparing the rate in days 3 to 9 following event attendance (high risk period) with days 1 and 2 and 10-16 (baseline period). Rate ratios were adjusted for estimates of underlying regional COVID-19 prevalence to account for population level fluctuations in infection risk, and events were grouped into broadly similar types.

RESULTS

From attendance data available for 188,851 attendees, 3357 people tested positive for COVID-19 during the observation period. After accounting for total testing trends over the period, incidence rate ratios and 95% confidence intervals for positive tests were 1.16 (0.53-2.57) for indoor seated events, 1.12 (0.95-1.30) for mainly outdoor seated events, 0.65 (0.51-0.83) for mainly outdoor partially seated events, and 1.70 (1.52-1.89) for mainly outdoor unseated multi-day events.

CONCLUSIONS

For the majority of event types studied in the third phase of the UK Events Research Programme, we found no evidence of an increased risk of COVID-19 transmission associated with event attendance. However, we found a 70% increased risk of infection associated with attendance at mainly outdoor unseated multi-day events. We have also demonstrated a novel use for self-controlled case series methodology in monitoring infection risk associated with event attendance.

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.

SARS-CoV-2 airborne infection probability estimated by using indoor carbon dioxide

Airborne transmission is one of the main routes of SARS-CoV-2 spread. It is important to determine the circumstances under which the risk of airborne transmission is increased as well as the effective strategy to reduce such risk. This study aimed to develop a modified version of the Wells-Riley model with indoor CO₂ to estimate the probability of airborne transmission of SARS-CoV-2 Omicron strains with a CO₂ monitor and to evaluate the validity of this model in actual clinical practices. We used the model in three suspected cases of airborne transmission presented to our hospital to confirm its validity. Next, we estimated the required indoor CO₂ concentration at which R₀ does not exceed 1 based on the model. The estimated R₀ (R₀, basic reproduction number) based on the model in each case were 3.19 in three out of five infected patients in an outpatient room, 2.00 in two out of three infected patients in the ward, and 0.191 in none of the five infected patients in another outpatient room. This indicated that our model can estimate R₀ with an acceptable accuracy. In a typical outpatient setting, the required indoor CO₂ concentration at which R₀ does not exceed 1 is below 620 ppm with no mask, 1000 ppm with a surgical mask and 16000 ppm with an N95 mask. In a typical inpatient setting, on the other hand, the required indoor CO₂ concentration is below 540 ppm with no mask, 770 ppm with a surgical mask, and 8200 ppm with an N95 mask. These findings facilitate the establishment of a strategy for preventing airborne transmission in hospitals. This study is unique in that it suggests the development of an airborne transmission model with indoor CO₂ and application of the model to actual clinical practice. Organizations and individuals can efficiently recognize the risk of SARS-CoV-2 airborne transmission in a room and thus take preventive measures such as maintaining good ventilation, wearing masks, or shortening the exposure time to an infected individual by simply using a CO₂ monitor.

Multi-objective optimization of mechanical ventilation with the aid of purifiers in two scenarios: Regular operation and mitigating the spread of respiratory infectious diseases

COVID-19 and its impact on society have raised concerns about scaling up mechanical ventilation (MV) systems and the energy consequences. This paper attempted to combine MV and portable air cleaners (PACs) to achieve acceptable indoor air quality (IAQ) and energy reduction in two scenarios: regular operation and mitigating the spread of respiratory infectious diseases (RIDs). We proposed a multi-objective optimization method that combined the NSGA-II and TOPSIS techniques to determine the total equivalent ventilation rate of the MV-PAC system in both scenarios. The concentrations of PM2.5 and CO2 were primary indicators for IAQ. The modified Wells-Riley equation was adopted to predict RID transmissions. An open office with an MV-PAC system was used to demonstrate the method's applicability. Meanwhile, a field study was conducted to validate the method and evaluate occupants' perceptions of the MV-PAC system. Results showed that optimal solutions of the combined system can be obtained based on various IAQ requirements, seasons, outdoor conditions, etc. For regular operation, PACs were generally prioritized to maintain IAQ while reducing energy consumption even when outdoor PM2.5 concentration was high. MV can remain constant or be reduced at low occupancies. In RID scenarios, it is possible to mitigate transmissions when the quanta were < 48 h-1. No significant difference was found in the subjective perception of the MV and PACs. Moreover, the effects of infiltration on the optimal solution can be substantial. Nonetheless, our results suggested that an MV-PAC system can replace the MV system for offices for daily use and RID mitigation.

Electronic Supplementary Material ESM

The Appendix is available in the online version of this article at 10.1007/s12273-023-0999-z.

Measurement and rapid assessment of indoor air quality at mass gathering events to assess ventilation performance and reduce aerosol transmission of SARS-CoV-2

To assess risk factors for COVID-19 transmission and address the closure of mass gathering events since March 2020, the UK Government ran the Events Research Programme (ERP), following which it reopened live events in sports, music, and culture in July 2021. We report the rapid post-occupancy evaluation of Indoor Air Quality (IAQ) and associated long-range airborne transmission risk conducted in the Environmental Study of the ERP. Ten large venues around the UK were monitored with CO2 sensors at a high spatial and temporal resolution during 90 events. An IAQ Index based on CO2 concentration was developed, and all monitored spaces were classified in bands from A to G based on their average and maximum CO2 concentrations from all events. High resolution monitoring and the IAQ Index depicted the overall state of ventilation at live events, and allowed identification of issues with ventilation effectiveness and distribution, and of spaces with poor ventilation and the settings in which long-range airborne transmission risk may be increased. In numerous settings, CO2 concentrations were found to follow patterns relating to event management and specific occupancy of spaces around the venues. Good ventilation was observed in 90% of spaces monitored for given occupancies. Practical applications: High-resolution monitoring of indoor CO2 concentrations is necessary to detect the spatial variation of indoor air quality (IAQ) in large mass gathering event venues. The paper summarises COVID-19 ventilation guidance for buildings and defines a methodology for measurement and rapid assessment of IAQ during occupancy at live events that can be implemented by venue managers. Comparisons of the CO2 concentrations measured during the events identified the spaces at high risk of long-range transmission of airborne pathogens. Building operators should be mindful of the ventilation strategies used relative to the total occupancy in different spaces and the occupant's activities.

Space and social distancing in managing and preventing COVID-19 community spread: An overview

The spread of COVID-19 at a large scale and at a rapid pace indicates the lack of social distancing measures at multiple levels. The individuals are not to be blamed, nor should we assume the early measures were ineffective or not implemented. It is all down to the multiplicity of transmission factors that made the situation more complicated than initially anticipated. Therefore, in facing the COVID-19 pandemic, this overview paper discusses the importance of space in social distancing measures. The methods used to investigate this study are literature review and case study. Many scholarly works have already provided us with evidence-based models that suggest the influential role of social distancing measures in preventing COVID-19 community spread. To further elaborate on this important topic, the aim here is to look at the role of space not only at the individual level but at larger scales of communities, cities, regions, etc. The analysis helps better management of cities during the pandemics such as COVID-19. By reflecting on some of the ongoing research on social distancing, the study concludes with the role of space at multiple scales and how it is central to the practice of social distancing. We need to be more reflective and responsive to achieve earlier control and containment of the disease and the outbreak at the macro level.

AlphaMobileSensing: A virtual testbed for mobile environmental monitoring

Environmental monitoring plays a critical role in creating and maintaining a comfortable, productive, and healthy environment. Built upon the advancements of robotics and data processing, mobile sensing demonstrates its potential to address problems regarding cost, deployment, and resolution that stationary monitoring encounters, which therefore has attracted increasing research attentions recently. To facilitate mobile sensing, two key algorithms are needed: the field reconstruction algorithm and the route planning algorithm. The field reconstruction algorithm is to reconstruct the entire environment field from spatially- and temporally-discrete measurements collected by the mobile sensors. The route planning algorithm is to instruct the mobile sensors where the mobile sensor needs to move to for the next measurements. The performance of mobile sensors highly depends on these two algorithms. However, developing and testing those algorithms in the real world is expensive, challenging, and time-consuming. To address these issues, we proposed and implemented an open-source virtual testbed, AlphaMobileSensing, that can be used to develop, test, and benchmark mobile sensing algorithms. AlphaMobileSensing aims to help users more easily develop and test the field reconstruction and route planning algorithms for mobile sensing solutions, without worrying about hardware fault, test accidents (such as collision during the test), etc. The separation of concerns can significantly reduce the cost of developing software solutions for mobile sensing. For versatility and flexibility, AlphaMobileSensing was wrapped up using the standardized interface of OpenAI Gym, and it also provides an interface for loading physical fields that were generated by numerical simulations as virtual test sites to perform mobile sensing and retrieving monitoring data. We demonstrated applications of the virtual testbed by implementing and testing algorithms for physical field reconstruction in both static and dynamic indoor thermal environments. AlphaMobileSensing provides a novel and flexible platform to develop, test, and benchmark mobile sensing algorithms more easily, conveniently, and efficiently. AlphaMobileSensing is open sourced at https://github.com/kishuqizhou/AlphaMobileSensing.

Electronic Supplementary Material ESM

the Appendix is available in the online version of this article at 10.1007/s12273-023-1001-9.