CDC WHO Global Webinar Series on Infection Prevention and Control for COVID-19

July 23 “Ventilation Considerations in Healthcare Settings for COVID-19”

Natural ventilation

Yuguo Li 李玉国
Department of Mechanical Engineering
/ School of Public Health
The University of Hong Kong
Acknowledgement

I thank my hard-working students/post-docs (since 2003), and collaborators in studying

Covid-19 transmission

HKU Mech Eng: Shenglan Xiao, Miao Te, Zhang Nan, Jack Chan, Chen Wenzhao, Zhao
Pengcheng

HKU Public Health: Hui-Ling Yen, Ben Cowling, Malik Peiris; CUHK: David Hui

Co-Is of outbreak analyses: Qian Hua (South East U), Hang Jian (Sun Yat-Sen U), Liu Li
(Tsinghua), Wei Jianjian and Lei Hao (Zhejiang U)

CDCs: Guangdong, Jiangsu and Hunan: Kang Min (Guangdong CDC), Ding Zhen
(Jiangsu CDC), Hu Shixiong (Hunan CDC) and many colleagues

To RGC, HMRF, NSFC and HKU for supporting us in studying environment control of
infection since 2003.

Disclosure: I have no conflict interest with any industry related to natural ventilation 2 `
Talks today

• Why ventilate?
• Natural ventilation – issues and benefits
• How to ventilate naturally
• List of materials

3`
Introduction: why ventilate?

Short-range <1.5 m Long-range

Ventilation
works when
there is long-
range airborne
transmission

Concentration =
Source
Ventialtion
Insufficient ventilation: The Guangzhou index patient A1 patient C2
Restaurant Outbreak
patient B1 patient A4
patient B3 TA patient C1
TB`
- Family A of 10 visited from Wuhan
TC
patient B2 patient A2
- Lunch on Jan 24 CNY eve
patient A3
patient A5
- 0.75-1.02 L/s per person ventilation T04
T17
T18

fan-coil unit
T05
column
T16 outdoor air path
T15
T06

T14
T13 exhaust fan
T11

T07 T10
T12

T08
fan-coil unit
reception
exhaust fan
T09
elevator

catering

toilet
Li Y., et al. Evidence for probable aerosol transmission of SARS-CoV-2 in a poorly ventilated
restaurant. https://www.medrxiv.org/content/10.1101/2020.04.16.20067728v1
Insufficient ventilation: Hunan bus outbreaks: a young man went home on 22 Jan on two buses and infected 10. ventilation rate of
approximately 1.72 L/s and 3.22 L/s per person
outdoor air supply fan

Air conditioning
supply inlets
air-conditioning return
Exhaust
exhaust fan
Skylight

Open window
Total duration: 3 hr 20 min
Total duration: 1 hr
Open window Busy urban/suburban Highway Suburban
Urban 20-30 km/hr 65-90 km/hr 30-40 km/hr
Countryside road driver
20-30 km/hr 30-60 km/hr
Changsha 15 km Pick-up 177 km Drop-off 3 km,
City D 6 km, 15 min 29km, 45 min Village H (town) 40 min 5 min 2 hr 25 min 5 min 5 min City D

13D

12D

11D

10D

9D
9D

8D

1D
3D
5A 5B 5C 5D 5E

4D
7D

6D

5D

2D
4A 4B

3A 3B

2A 2B

1A 1B

D
13C 13E 13B

11C

10C
12C

7C

1C
9C

8C

3C
4C
6C

2C
5C
10B
11B
12B
4C 4D

6B

5B

4B

1B
3B
7B
C
C

6A

5A

4A

1A
3A
10A

7A
3C

2C

11A
13A

12A
door
Ventilation refers to supply of outdoor or “properly
filtered” air in a building and distribute within it.
1. Ventilation flow rates Bedroom Bathroom
2. Airflow direction
3. Air distribution
“The necessity of providing hospital
Ventilation needs in hospitals with more than the usual means of
ventilation has long been
• Differs from conventional buildings in terms of needs recognized…Yet, in spite of … some
• Infectious aerosols may be generated from medical procedures. careful studies by physicians,
• Ventilation requirements can be much higher than non-hospital engineers and architects …, it must be
environments.
confessed that the results obtained
• Patients in hospitals can be more sensitive to thermal
discomfort, such as draft. have too often been unsatisfactory”
• Energy consumption can be much higher than in a non-hospital
environment. John S Billings, 1893.
• Most hospitals operate 24 /7/365 .
7 ` of 60
The same can still be said today.
Ventilation is important to airborne (or airflow)
transmission of Covid-19 in at least two aspects

• An insufficient ventilation leads to a probably non-airborne

transmission of SARS-CoV-2 to long-range airborne transmission.
Poor ventilation leads to opportunistic airborne.

• Recirculation bubbles (in minimizing inflow of clean air) or

stratified air layers (in minimizing dilution) may also enhance the
airborne transmission with unfavourable release of infectious
aerosols.

Such opportunistic airborne transmission is not difficult to control with

better ventilation provision or engineering design. It is easy to control
the long-range airborne portion of the Covid-19 spread – the roles of
8`
HVAC engineers.
CDC/WHO -recommended isolation room design

• 12 ACH
• Negative
pressure for
airflow from
corridor to
cubicle and then
to toilet

WHO Interim Guidelines, 2007, page 39 9`

http://www.who.int/csr/resources/publications/WHO_CDS_EPR_2007_6c.pdf
The idea of Sanatorium (1863-)

Dr Edward L Trudeau (1848-1915)

Dr Trudeau built the first Sanatorium

near Saranac Lake, NY in 1882 in US.
Why NatVent was abandoned in the US in 1930s and later in
many other places?
Disadvantages – difficult to control, outdoor pollution, changing climate,
difficult to combine with heating/cooling/ humidification/
dehumidification, conflict with fire, security, deep plan design is difficult
etc.
• MVAC works at nearly all climate • NatVent works well at moderate
conditions weather
• MVAC consumes more energy • NatVent maximizes the provision of
hence tries to provide minimum outdoor air for removing heats
outdoor air
• NatVent not suitable for deep
• MVAC suitable for deep buildings
buildings
• Potential conflict with fire regulation
• Compatible with modern smoke
regulation, safety and safety requirements
We talk about today’s natural ventilation
• Developments in computers and new control technology make it possible
control natural ventilation in many applications. This also attributes to new
development in ventilation openings etc.

• Significant improvement in our understanding of turbulent air flows in

buildings. Analysis methods and prediction and design tools have now been
used by engineers for building ventilation design.

• Reliability of natural ventilation was a real issue. The idea of hybrid design
makes the reliability not an issue any longer.
 IEA Annex 35 IVEG Building, Belgium
PROBE Building, Belgium
HybVent Buildings
Søren Aggerholm IJV SE Feb 2003

https://www.iea-
ebc.org/Data/publications/EBC_Annex_35_tsr.pdf

Fujita Technology Centre, Japan

B&O Headquarters, Denmark

Guzzini Illuminazione, Italy

Tånga School, Sweden Waterland School,

The Nederlands

Bertolt-Brecht Gymnasium,
Germany
13
Grantham Hospital -A TB hospital that has been
naturally ventilated since 1950s
Spot cooling

Ceiling fans
Open windows for 24 hrs a d
and 365 days a year

14 `
Measured air change rate
in Grantham hospital by
using INNOVA analyzer
at: Cubicle A
In collaboration with Dr WH Seto

Cubicle B (sampler at
center of cubicle before
renovation, sampler at
close to balcony after
renovation)
15 `
WHO 2009 NatVent Guideline – key ideas

• For natural ventilation, a minimum hourly averaged

ventilation rate of 160 L/s/patient for airborne
precaution rooms (with a minimum of 80 L/s/patient).

160 l/s

80 l/s

• When natural ventilation alone cannot satisfy the

requirements, mechanically assisted natural ventilation
system should be used.
• Overall airflow should bring the air from the agent
sources to areas where there is sufficient dilution, and
preferably to the outdoors.
One-side Corridor Type - Wind from ward to corridor

Section Plan Floor Plan

Opposite flow design would be better,
? but even for this flow, if the ventilation
rate is very high, it is OK
 Central Chimney type -Opposing Wind

Floor Plan

Section Plan

?
For this flow, if the ventilation rate is
very high, it is OK.

Note opposite flow design is not easy

due to lack of wind
Courtyard Type (Inner corridor) -Wind from ward to corridor to
courtyard

Corridor

Courtyard

Section Plan
For this flow, if the
ventilation rate is very high,
it is OK.
? Note opposite flow design Floor Plan
is not easy due to lack of
wind
 Corridor

Corridor?
Courtyar
d

Corridor

Courtyard

Downstream?
20 ` of 46
Possible suggestions to hospital users

• Seek advices from your mechanical engineers (HVAC)

• Do not turn off mechanical ventilation if you cannot open
your windows just for the sake of using NatVent
• One simple criterion: if you can smell other’s breath at a
distance, ventilation may not be sufficient.
• Be careful with calm weather.
• Using hybrid systems if possible, e.g. spot cooling, but
condensation may occur
21 `
List of materials

• Chartier, Y., & Pessoa-Silva, C. L. (2009). Natural ventilation for infection

control in health-care settings. World Health Organization.
https://www.who.int/water_sanitation_health/publications/natural_ventilation/e
n/ Languages: English, French, Spanish
• CIBSE: AM10: Natural ventilation in non domestic buildings.

22 `
Thank you

23 `