From Healthcare-Associated Bacterial Infection to Building Design

Arno Germond; Garance F Upham

doi:10.37871/jbres1866

ISSN: 2766-2276

Biology Group. 2024 January 09;5(1):013-015. doi: 10.37871/jbres1866.

Subject area(s)

Infectious Diseases

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Mini Review

From Healthcare-Associated Bacterial Infection to Building Design

Arno Germond* and Garance F Upham

AMR Think-Do-Tank, Geneva International, Maison des associations 15 Rue des Savoises 1205 Geneva, Switzerland

*Corresponding author: Arno Germond, AMR Think-Do-Tank, Geneva International, Maison des associations 15 Rue des Savoises 1205 Geneva, Switzerland E-mail:

Received: 30 November 2023 | Accepted: 05 January 2024 | Published: 09 January 2024

How to cite this article: Germond A, Upham GF. From Healthcare-Associated Bacterial Infection to Building Design. J Biomed Res Environ Sci. 2024 Jan 09; 5(1): 013-015. doi: 10.37871/jbres1757, Article ID: jbres1757

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SARS-CoV-2 showed how measures against airborne pathogens are critical in clinical environments. Bacteria make no exception. Healthcare-associated or Hospital-Acquired Infections (HAIs) represent one of the major concerns in the Western world, impairing the clinical outcome of up to 15% of all hospitalized patients [1]. Every year in the European community about 3.2 million patients acquire a HAI, and 37,000 die as a direct consequence of HAI, and the presence of Multi-Drug Resistant (MDR) bacteria is a growing concern [1,2].

The spread of airborne pathogens such as tuberculosis has been studied since at least 1959, and much work has been done to understand the transmission of airborne pathogens in medical institutions [3,4]. The masterful work of Lydia Bourouiba on the fluid dynamics of respiratory clouds helps us visualize and model how pathogens spread [5,6]. In light of recent work and studies done in the past 20 years, it is desirable to translate these observations into practice. A priority is to reduce the risks of disease spread, especially in medical facilities, public schools, and public places. Efforts have been being carried out in many countries to improve hygienic practices by hospital staff and patients, notably to avoid contact with water contaminated by antibiotic-resistant bacteria. Such practices reduce the possibility of direct transmission by contact. Transmission by airborne pathogens, however, is harder to control [1]. Medical facilities such as hospitals are hotspots for pathogenic bacteria. They offer many ecological niches favoring the emergence and spread of antibiotic-resistance genes among bacteria [4]. Among all the measures that can be taken, a key one is the building ventilation.

In this short article, we question the underestimated role of natural ventilation in healthcare facilities and in extenso public buildings. It suggests smart engineering/architecture of buildings can be designed with natural ventilation and the aim to reduce bacteria-caused HAIs. This article concludes with three leverage points to encourage the implementation of natural ventilation [7].

As of today, medical facilities such as hospitals heavily rely on the use of Air-Conditioning (AC) systems to ventilate the rooms, from patient room to surgery rooms. AC have become a necessary product, used in many hospitals, especially in the climate crisis where heatwaves become more frequent. However, the building ventilation system may also facilitate the spread of airborne bacteria, creating ecological niches that can benefit the spread of antibiotic-resistant genes between bacteria. Even exposures to low levels of antibiotics were shown to increase the genetic diversity in microbial populations via the activation of the bacterial SOS response, resulting in an increased mutation rate throughout the genome [8]. Together with other biological mechanisms, the available pool of genetic and phenotypic diversity in bacterial populations exposed to antibiotics encourages the emergence of pathogenic strains. So far, the major action that has been taken to avoid the spread of airborne pathogens in hospitals has been to ban the use of aerosols, which were found to participate in the transfer of antibiotic-resistant genes in various kinds of facilities [9,10].

Complementary or opposite to mechanical ventilation, the interest in natural ventilation is gaining interest, and the work of L. Bourouiba surely contributes to this interest. Natural ventilation allows for renewing the volume of air through a comprehensive design of the openings, corridors, and rooms. Modeling studies could help study how to change the airflow or temperature to minimize the risk in a hospital. Several studies have reported the success of natural ventilation in reducing the spread of airborne pathogens [11,12]. The absence of natural ventilation, on the other hand, is also known to have major dramatic consequences. The Queen Elizabeth University Hospital (QEUH) in Glasgow, Scotland, has been pointed out in 2020 for severe outbreaks and at least four deaths caused by issues with its (mechanical) ventilation system [13].

So why natural ventilation has not been implemented in medical facilities yet?

Our think-tank engaged in discussions with architects (e.g. [10]). It led us to conclude that urban planners, industries, and builders are not interested in natural ventilation design, as it requires a strong knowledge (which requires qualified workers, so more costs) and careful design adapted to the surrounding urban context. The building industry is, like others, driven by margin, speculation, and land value. It aims to maximize profits in a short time. Rajan Rawal, a professor of architecture and city planning at Cept University, India, denounced that in the past decades, the speed of planning and construction have been shortened under financial pressure. In this context, actors do not necessarily want buildings with reduced energy consumption and better ventilation. In particular, if the development costs to study alternative ventilation systems are too high. Mr. Rawal encourages incentive or legal obligation to do so.

Perhaps the costs associated with energy consumption will be a strong economic incentive for decision-makers to develop natural ventilation in healthcare facilities. In 2018 in Beijing, during a heatwave, “50% of the power capacity was going to air conditioning,” reported John Dulac, an analyst at the International Energy Agency (IEA) [14]. But there are also proactive solutions to encourage the implementation of natural ventilation in medical facilities. Three of them are mentioned here.

First, implementing natural ventilation against pathogens requires certain know-how in mathematics, civil engineering, and microbiology. The building design is based on quantitative data. Balancing the sizes of the openings, the surface areas of the walls, the thermal properties, the window’s location, the rate of air renewable, etc. Hence, comprehensive studies to test parameters and designs are desirable. One could argue there is a lack of in situ experiments to increase the know-how and make it readily available. Academics have a role to play here and should be encouraged by the building industry. Such knowledge would not only benefit the innovative design of healthcare facilities, but also of public spaces, and housing. Second, natural ventilation also requires more policy support. One can observe that there is a major implementation of AC in buildings, especially housing in India, Asia, America, despite the urgent need to reduce energy consumption and environmental impacts. Encouraging policies in favor of natural ventilation will increase the resilience of cities while improving general public health.

Last but not least, another aspect is how one educates the new generation of architects themselves. Arguably, an entire generation of architects and builders include the need for air conditioning in any building. Architecture is no more a standalone profession, and multi-disciplinary teams to properly design the next generation of buildings should be encouraged.

To conclude, after 20 years of research on natural ventilation, healthcare workers and the general public must make the decision-makers and the building industry understand the benefits of buildings “equipped with” natural ventilation. The recent case of bacterial outbreaks in 2020 at the Queen Elizabeth University Hospital (QEUH) in Glasgow13 should serve as a warning. Natural ventilation is a solution to the problem of energy consumption9 while it may greatly contribute to reducing the occurrence of severe pathogen outbreaks.

Acknowledgment

We thank Suzan Roaf and Rajan Rawal for the interesting discussions on architecture, and scientists of our board of experts for discussions on healthcare and epidemiology.