Journal of Hospital Infection 106 (2020) 318e324

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Journal of Hospital Infection

journal homepage: www.elsevier.com/locate/jhin

Airborne particle dispersion around the feet of surgical

staff while walking in and out of a bio-clean operating
theatre
S. Sunagawa a, b, H. Koseki a, *, C. Noguchi c, A. Yonekura c, U. Matsumura a,
K. Watanabe a, b, M. Osaki c
a
Department of Health Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
b
Department of Rehabilitation, Wajinkai Hospital, Nagasaki, Japan
c
Department Orthopedic Surgery, Nagasaki University Graduate School of Biomedical Sciences, Japan

A R T I C L E I N F O S U M M A R Y

Article history: Background: Bacterial contamination by airborne particles is one of the most important
Received 10 May 2020 factors in the pathogenesis of surgical-site infections.
Accepted 14 July 2020 Aim: This study aimed to identify the generation and behaviour of airborne particles
Available online 21 July 2020 around the feet of surgical staff while walking in and out of an operating theatre.
Methods: Two physicians and two nurses walked in and out of a bio-clean theatre under
Keywords: laminar airflow, either individually or as a group. The generation and behaviour of airborne
Surgery particles was filmed using a fine-particle visualization system, and the number of airborne
Airborne particles particles per 2.83 m3 of air was counted using a laser particle counter. Each action was
Surgical site infection repeated five times, and particle counts were evaluated statistically.
Walk Findings: Airborne particles were generated from the floor and by the shoes and gown
hems of the participants, whether walking individually or as a group. Numerous airborne
particles were generated by the group, and significantly more particles, especially those
measuring 0.3e0.5 mm, were carried up to the level of the operating table by the group
than by individuals (P<0.01).
Conclusions: The results of this study provide a clearer picture of the dispersion and
distribution of airborne particles around the feet of staff walking in and out of an oper-
ating theatre. The findings suggest that to reduce the incidence of bacterial con-
tamination and risk of surgical site infections, surgical staff should walk calmly and
independently, if possible, near sterile areas.
ª 2020 The Author(s). Published by Elsevier Ltd
on behalf of The Healthcare Infection Society. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

* Corresponding author. Address: Department of Health Sciences,
Nagasaki University Graduate School of Biomedical Sciences, 1-7-1
Sakamoto, Nagasaki, 852-8520, Japan. Tel.: þ81 95 819 7900; fax: þ81
95 819 7907.
E-mail address: koseki@nagasaki-u.ac.jp (H. Koseki).
Surgical site infections (SSIs) cause significant morbidity and
mortality. To date, preventive measures against SSIs have
included disinfecting surgical wounds, sterilizing devices and
instruments and the use of bio-clean theatres. However, SSIs

https://doi.org/10.1016/j.jhin.2020.07.016
0195-6701/ª 2020 The Author(s). Published by Elsevier Ltd on behalf of The Healthcare Infection Society. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 S. Sunagawa et al. / Journal of Hospital Infection 106 (2020) 318e324
still occur in 0.2e17.3% of all orthopaedic surgeries [1,2]. SSIs
related to prosthetic arthroplasty (prosthetic joint infections
(PJIs)) are particularly devastating complications because
treatment requires extended hospitalization, increased public
costs, additional procedures and a high risk of death at con-
siderable expense [3,4]. In the USA, approximately 1.2 million
arthroplasties are performed annually, and the incidence of
postoperative prosthetic hip or knee infection is reportedly
2.0e2.4% [5,6]. The number of cases of PJIs will surely increase
because an increasing number of primary implantations are
being performed, and thus, the economic burden of treatment
is likely to reach 1.6 billion USD (confidence interval,
1.53e1.72 billion USD) in 2020 [3,6,7].
Though SSIs are multifactorial in origin and include both
patient- and procedure-specific factors, airborne infection is
considered to be a potential source of exogenous bacterial
contamination [8e12]. During surgical procedures, bacteria-
laden airborne particles, including textile fibres, dust par-
ticles, skin flakes and respiratory aerosols, can settle on sur-
gical instruments or enter surgical sites directly, resulting in SSI
[13e17]. Hansen et al. noted that bacterial counts were lower
in environments with fewer airborne particles, and that the
number of particles 5 mm in diameter closely correlated with
bacterial concentrations before incision and during operation
(P0.01, Spearman correlation) [18]. Other studies have
associated 80e90% of pathogenic bacteria detected in surgical
wounds with airborne particles in operating theatres [19], with
airborne skin flakes acting as vectors for pathogenic micro-
organisms that infect surgical wounds [20]. Thus, surgical site
contamination by airborne micro-organisms plays a central role
in the exogenous pathogenesis of SSIs, and airborne particles in
operating theatres should be controlled and minimized to
protect patients.
Staphylococcus aureus is the micro-organism most fre-
quently responsible for SSIs, and airborne transmission has
been implicated in nosocomial outbreaks of meticillin-resistant
S. aureus (MRSA) [21]. MRSA ranges from 0.8 to 1.0 mm in
diameter and thus, not only large, but also small airborne
particles aggregated by static electricity can be highly popu-
lated with pathogenic bacteria. The number of wound infec-
tions after arthroplasties is influenced by the air quality in
operating theatres [10]. Based on the above evidence, ultra-
clean ventilation systems and laminar airflow (LAF) ceilings
have been installed in operating theatres in many countries.
LAF, which is commonly used in bio-clean theatres [22], creates
a homogeneous, low-turbulence vertical airflow directly over
the operating area through a combination of high airflow rates
and high-efficacy particulate air (HEPA) filtration [18]. LAF with
HEPA filters can remove approximately 99.97% of airborne
particles larger than 0.3 mm, resulting in minimal bacterial
counts in the air [16,23].
However, some publications have questioned whether LAF
ventilation confers any benefit [24], and even suggest that
postoperative SSI rates may be higher after surgery under LAF
conditions compared with conventional operating theatres
[25,26]. The most recent global guidelines on the prevention of
SSI from the World Health Organization also suggest that LAF
ventilation systems should not be used for patients undergoing
total arthroplasty [27]. High activity during the preoperative
preparation of patients results in the dispersal of large numbers
of airborne particles [28]. Hansen et al. found the highest
319
concentration of ultra-fine particles near the operative field
before incision [18]. Our previous study revealed that pre-
operative activities such as unfolding surgical gowns, removing
gloves, applying or cutting stockinette cloths and covering
limbs with a holed drape generate large numbers of airborne
particles [29]. Several recent studies have indicated that air-
flow in bio-clean operating theatres is affected by the number
of persons present and doors opening and closing [13,30e34].
Particles that have settled on an unsterile floor can easily be
dispersed by air eddies generated by opening doors and foot
traffic. Reportedly, S. aureus, including MRSA, can survive for
days to weeks on dry surfaces depending on their concentration
and the room temperature and humidity [35,36]. Therefore,
the prediction and reduction of particle dispersions are key to
lowering the risk of contamination by airborne micro-
organisms. However, airborne particles are invisible, and
therefore, the mechanisms or degree to which they are gen-
erated by staff turnover remains unclear. In addition, the dis-
persal of airborne particles while entering or exiting an
operating theatre has not been visualized. To protect patients
against infection, all personnel involved in surgical procedures
should help reduce the risk of SSIs by understanding and pre-
venting situations that increase the number of airborne par-
ticles in operating theatres.
Therefore, the present study aimed to quantify the dis-
persion and distribution of airborne particles caused by walking
in and out of a bio-clean operating theatre.
Materials and methods
Experimental design
Four surgical staff members (two physicians and two nurses)
were recruited for the present study. After donning a surgical
cap and mask, each participant put on a surgical gown (JG-
100, Hopes Co., Ltd., Hokkaido, Japan) and latex powdered
surgical gloves (Tradition, Medline International Japan,
Tokyo, Japan). All surgical garments used in this study were
made from typically used spun-lace non-woven fabric consist-
ing of 45% wood pulp and 55% polyester pulp.
The surgical staff entered and exited the LAF-equipped bio-
clean theatre individually and as a group to mimic some of the
actual activities that occur during major orthopaedic surgeries.
The bio-clean theatre was an ISO class 7, Fed. Standard class
10000 with a HEPA filter. The LAF settings were as follows: wind
velocity, 0.44 m/s; theatre temperature, 21.9 C; humidity,
32.4%; and air pressure, 15 Pa (1.53 mmAq) positive. After the
door was opened, the staff walked into the operating theatre
through either individually or as a group, passed by the
instrument table (height, 1 m; width, 80 cm; depth, 50 cm) and
proceeded toward the operating table (height, 1.1 m; width, 50
cm; length, 212 cm) at the centre of the theatre. The partic-
ipants wore their personal walking shoes, which had been
purchased before the experiments. To exit, the individuals or
group left the centre of the operating theatre and passed by
the instrument table. After the door opened, the staff exited
the operating theatre. The stride length was set to about 100
cm, walking speed 50 cm/s and stride time 2 s. When in a
group, the four participants walked in a line one behind the
other separated by about 50 cm. The generation and behaviour
320 S. Sunagawa et al. / Journal of Hospital Infection 106 (2020) 318e324

Figure 1. Entering the bio-clean operating theatre individually. The fine-particle visualization system shows the dispersal of reflective
airborne particles (bright dots). The individual walked from the left (back) to the right (front) of the figure. Particle dispersion from the
shoes and gown hems occurred in the lateralesuperior direction at the mid-stance phase of the gait cycle (arrows).

of airborne particles were filmed using a fine-particle visual-
ization system (Shin-Nihon Air Technologies Co. Ltd., Tokyo,
Japan) with a green laser. After generating a uniform laser light
sheet, light reflected from airborne particles was filmed using a
highly sensitive camera with an interference filter. Movies were
converted into 1/30-s images, and particle density hazard maps
were created using MATLAB image analysis software (Math-
Works Co. Ltd., Tokyo, Japan). Risk areas were classified as
ultra-high (red), high (light blue) or medium (white) zones. The
number of airborne particles per 2.83 m3 of air was determined
using a KC-52 laser particle counter (RION, Tokyo, Japan)
located 30 cm from the operating table, and the mean was
taken as the measured value. Samples were collected at 1.1 m
above the floor to simulate the height of the operating or
instrument tables. A sampling tube (internal diameter, 6 mm)
was attached to the air intake port of the particle counter, and
the measurement interval was set to 1 min (2.83 m3 of air per
minute). Particles were separated based on size distributions
of 0.3e0.5, 0.5e1.0, 1.0e2.0 and 2.0e5.0 mm. The theatre
used in this study was cleaned every morning and evening, and
the floor was wiped before each performance. The particle
counter placed 1.1 m above the floor in an empty theatre
constantly showed 50e200 particles/min, and no walking
actions were performed until the particles had finished dis-
persing (particle count <200/min).
Ethics approval and consent to participate
All participants provided written, informed consent to par-
ticipate in the study. The Ethics Committee at the Nagasaki
University Graduate School of Biomedical Sciences granted an
exemption from ethics approval because humans and human
materials were not the subjects of the study, and data were not
derived from patients.
 S. Sunagawa et al. / Journal of Hospital Infection 106 (2020) 318e324
Figure 2. Group entry into the bio-clean theatre. The generated particles were widely dispersed and carried higher by subsequent
members of the group.
Statistical analysis
Each walking task was repeated five times. Particle counts
were compiled for statistical analysis, which consisted of one-
way analysis of variance multiple comparison tests followed by
post hoc TukeyeKramer and BonferronieDunn multiple compar-
ison tests. All data were analysed using SPSS version 22.0 (SPSS,
Chicago, IL, USA). Values are expressed as means  standard
deviations. Statistical significance was defined as P<0.01.
Results
The dispersal of reflective airborne particles was evidenced
by small bright dots through the fine-particle visualization
system. In the absence of traffic, airborne particles in the bio-
clean theatre drifted down under the LAF and slowly moved
away from the centre to the perimeter of the theatre.
321
Entering the operating theatre
Opening the door resulted in floating fine particles moving
quickly towards and through the open door. When the partic-
ipants walked individually, many particles were dispersed from
their shoes and gown hem in the lateralesuperior direction,
particularly at the mid-stance phase of the gait cycle
(Figure 1). Moreover, particles became airborne because of
turbulent flow immediately behind the individual. The number
of airborne particles clearly increased when the participants
moved as a group, and the particulates were carried to an area
above the instrument table by turbulent flow generated by the
single-file movement of the participants moving as a group
(Figure 2). After the participants left, the dispersed particles
migrated slowly toward the door. The constructed hazard map
indicated that the risky zone became higher and wider when
the participants walked as a group compared with individually
(Figure 3). Table I shows the mean number of airborne particles
322 S. Sunagawa et al. / Journal of Hospital Infection 106 (2020) 318e324

Figure 3. Particle density hazard map. Risk areas are shown as ultra-high (red), high (light blue) and medium (white) density zones.
Walking in the operating theatre individually (a) and as a group (b).

measured during entry and exit, both individually and as a
group. More particles, especially those 0.3e1.0 mm in size,
were detected when the participants walked as a group than as
individuals (P<0.01).
Exiting the operating theatre
Similar to the results obtained when the participants
entered the bio-clean operating theatre, many airborne par-
ticles were dispersed around the feet, more were scattered
and carried by the turbulent flow created by the participants
and the number of particles was higher when the participants
moved as a group rather than as individuals. Fine particles
notably hovered for a short period in the air. When a partic-
ipant approached the exit and the door opened, airborne
particles started to flow through the open door. Hazard maps
showed that the risky zone was higher and wider when the
participants walked as a group compared with as individuals.
Table I shows that significantly higher counts of particles
0.3e1.0 mm in size were generated by the group than by indi-
viduals (P<0.01). By contrast, the total number of particles of
all size categories did not differ significantly between the
participants entering and exiting the theatre.
Discussion
The use of a fine-particle visualization system revealed many
airborne particles dispersed in the lateralesuperior direction
around the feet of surgical staff as they entered and exited a
bio-clean theatre under LAF. The sources of these particles were
the hems of surgical gowns, shoes and the floor. Many bacteria-
laden skin flakes [37,38] can migrate from uncovered skin (e.g.,
neck, face) or through gaps in the material used to manufacture
the garments worn by surgical staff [30]. Dharan and Pittet
reported that >50% of all infections arising after general surgery
were caused by the normal skin flora of patients and healthcare
workers [23]. Therefore, particles on human skin, as well as skin
flakes, could increase the risk of bacterial contamination. Air-
borne particles dispersed from the hems of surgical gowns and
shoes likely contain many skin flakes. In addition, skin flakes and
textile fibres that settle on unsterile floors can easily be dis-
persed by air eddies generated by foot traffic [30,31,39],
thereby acting as vectors for bacterial transmission
[13e16,18e20]. In particular, large numbers of airborne par-
ticles were carried higher when the participants walked in single
file in a group in turbulent airflow. It is currently thought that
there is little benefit from rigorously enforcing the changing of
footwear to dedicated operating theatre shoes [40,41]. How-
ever, Amirfeyz et al. reported that shoes worn outside have a
high level of bacterial contamination (98%), mainly by
coagulase-negative staphylococci, Bacillus spp. and coliforms
[42], thereby reducing the cleanliness of an operating theatre
floor, and stirring up bacteria-laden airborne particles from the
operating theatre floor and increase the risk of SSIs.
The movies recorded during this study revealed that sus-
pended airborne particles flowed slowly from the centre of the
bio-clean theatre to the periphery under LAF, and that a rela-
tively fast current of air toward and through the doorway was

Table I
Mean number and standard deviation of airborne particles (particles/2.83 m3)
Particle size category (mm) 0.3e0.5 0.6e1.0 1.1e2.0 2.1e5.0 Total
Enter Individually 1052.2 (162.2) 146.1 (24.5) 48.5 (17.6) 56.9 (16.3) 1303.6 (159.1)
Group 1773.2 (256.1)* 226.6 (32.3)* 51.1 (16.8) 51.7 (10.2) 2102.6 (270.4)*
Exit Individually 1040.0 (91.5) 159.1 (34.2) 42.2 (9.4) 44.6 (10.5) 1285.9 (79.3)
Group 1653.8 (221.9)* 225.5 (29.5)* 45.1 (10.9) 48.0 (8.3) 1972.4 (223.1)*
*P<0.01 compared with walking individually.
 S. Sunagawa et al. / Journal of Hospital Infection 106 (2020) 318e324
generated immediately after the door opened. While entering,
staff moved against this air current with high air resistance,
causing turbulent diffusion behind the body, even when only one
individual entered. When entering as a group, the particles
stirred up by the first person were carried higher by successive
group members, and thus, more particles were generated at the
level of the operating table by the group than by individuals. The
disposable overshoes commonly used to protect the feet of
surgical staff might cause considerable turbulent diffusion due
to their fluttered shape. Exiting the operating theatre also
produced many airborne particles around the feet of the group.
These particles were dispersed high and wide by turbulent flow,
in the same manner as when the participants entered. However,
in contrast to when the participants entered the operating
theatre, there was no fast air current towards the outside, and
the generated fine particles hovered in the air until the door was
opened. This may be one reason why the number of airborne
particles did not decrease as the participants exited compared
with as they entered, even though the staff walked in the same
direction as the LAF. Importantly, from the viewpoint of pre-
venting SSIs, the surgical staff should consist of as few people as
possible, and all staff should walk calmly when entering or
exiting a bio-clean theatre. Moreover, sterile instruments,
items and tables should not be located near the pathway
between the entrance and the operating table.
This study had some potential limitations. We focused on
the dispersal of airborne particles while entering or exiting a
bio-clean operating theatre and evaluated the nature of air-
borne particle dispersion and particle counts at the level of the
operating table. However, we could not completely reproduce
the actual operating situation, which involves many surgical
staff and patients over a longer time frame, because of the
apparatus setting. Thus, further study simulating other various
experimental situations is necessary. Although bacterial counts
at surgical sites correlate with airborne bacteria and particle
counts [8e10], whether they correlate directly with SSI rates
has not been demonstrated [9]. In this study, we did not assess
the actual relationship between particle counts, the incidence
of bacterial contamination and the rate of SSIs; however, more
particles carrying bacteria increase the possibility of bacterial
contamination [9]. We simulated several patterns of walking
activities within the bio-clean operating theatre to provide
surgical staff with a clearer picture of the dispersion and dis-
tribution of particles that could contaminate surgical sites or
sterile areas. To reduce the risk of contamination by airborne
microorganisms, surgical staff have to take measures to mini-
mize the production of airborne particles and decrease particle
counts in sterile areas while entering or exiting bio-clean the-
atres under LAF.
In conclusion, fine-particle visualization and automatic
particle counting revealed that large numbers of airborne
particles are produced from the shoes, gown hems and the floor
as personnel walk in and out of an operating theatre. Partic-
ipants walking in single file in a group disperse numerous air-
borne particles higher and wider than when walking
individually.
Acknowledgements
The authors gratefully acknowledge Central Uni Co. Ltd.
(Tokyo, Japan) for providing access to a functional operating
323
theatre. The authors have not and will not receive benefits or
funding from any commercial party directly or indirectly rela-
ted to the subject of this article.
Author contributions
All authors substantially contributed to this article. S.S. and
H.K. conceived and designed the study. S.S., C.N., H.K., U.M.
and K.W. participated in the experiments and gathered the
data. C.N., H.K., A.Y., U.M. and M.O. analysed and interpreted
the data. S.S. wrote the initial drafts of the manuscript. H.K.
and M.O. statistically analysed and ensured the accuracy of the
data. All authors read and approved the final version of the
manuscript.
Conflict of interest statement
None declared.
Funding sources
This work was partially supported by the Grants-in-Aid for
Scientific Research of Japan Society for the Promotion of
Science, Grant Number 232024000.
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