Strategies for Infection Control in the Workplace by ElevarDesignGroup

Strategies for Infection Control in the Workplace A Checklist

April 28, 2020 | Elevar Design Group Regan Henry, PhD, RA, LEED AP, LSSBB | Greg Otis, AIA | Tony Lozier, PE, LEED AP | Dara Baldrige, IIDA, LEED AP

Strategies for Infection Control in the Workplace A Checklist

April 27, 2020 | Elevar Design Group Regan Henry, PhD, RA, LEED AP, LSSBB | Greg Otis, AIA | Tony Lozier, PE, LEED AP | Dara Baldrige, IIDA, LEED AP

This paper is a review of strategies Facility Managers may utilize in response to the COVID-19 pandemic. As the nation plans for the re-opening of the economy and transition of employees back into the workplace, Facility Managers should understand their role in keeping inhabitants healthy. Our report examines how the workplace may be adapted to better protect employees from infectious disease. Consider using this as a checklist for planning the reengagement of your staff within your facility.

What is COVID-19? “Coronavirus” is a generic term describing a large family of viruses. COVID-19 is the disease caused by the virus SARS-CoV-2, Severe acute respiratory syndrome coronavirus 2. SARS-CoV-2 is a betacoronavirus, like MERS-CoV and SARS-CoV. Betacoronavirus are enveloped, positive-sense, single-stranded RNA viruses of zoonotic, transmissible to humans from animals, origin.1 COVID-19 is nearly twice as contagious as the typical flu with a reproductive ratio (R0) greater than 2. When a R0 is between 0 and 1, a virus is prevented from spreading and the disease will die out in a population. When a R0 is greater than 1, the disease will spread.2 The threat of COVID-19 will be present in our communities until (1) a vaccine is developed or (2) the R0 drops below 1 due to preventative measures such as isolation and quarantine or reaching a point of herd immunity; Neither solution is quick.3 The COVID-19 virus, SARS-CoV-2, is measured between 60 to 140 nm and averaged to 125nm or 0.125 Microns for discussion. The virus often travels in larger vacuoles of biological aerosols – transmitted through coughing and sneezing - which range in size from 0.5-3 Microns.

How is it Transmitted? The two main methodologies for infection are (1) person to person or (2) transferred via an intermediate surface. A study published in The New England Journal of Medicine shows that the virus could survive in droplets for up to three hours after being coughed out into the air and can remain airborne for several hours in still air.4 While the virus can remain infectious on a surface at room temperature for up to nine days. The current consensus is that the virus is spread predominantly via large droplet transfer. This means droplets too large to remain airborne are spread through speaking, coughing, or sneezing within a close range of other people. The Center for Disease Control (CDC) puts this range at about six feet – hence the social distancing requirement of six feet separation.5

Strategies for Infection Control in the Workplace, A Checklist April 28, 2020

Strategies for Infection Control Policy Social Distancing

The U.S. government has mandated that all people should keep six feet of social distance, limit or cancel larger gatherings, and stay at home and isolate one’s self if showing symptoms of the disease. While maintaining social distance plays a large part in the battle against the spread of the virus, we know the virus can last in the air and on surfaces long after an infected person has moved on. Social distancing is best performed in separate and isolated zones – promoting working from home or a dedicated space that has a six-foot clear radius. All hoteling stations, common areas, and conference rooms require thorough sterilization between use.

Encourage Working from Home

Working from home remains the safest option for most. Research-based consulting firm, Global Workplace Analytics, estimates 56% of the U.S. workforce holds a job that is compatible with remote work6 while a 2019 poll found 62% of employees say they could work remotely at least one day a week7. Until a vaccine is identified, employees able to work from home are safest staying home. With today’s technology few physical barriers to productivity exist. In fact, one may work as efficiently and effectively from home as the office, while eliminating the cost and time of commute. Companies are encouraged whenever possible to leverage both the capability and the desire of employees to work from home during this pandemic.8

De-densification

Choreographed Circulation

Temperature and Travel History Checks

Personal Protection Equipment

To enforce social distancing, Facility Managers have adjusted the denominator for the maximum space occupancy calculation. A suggested six-foot radius per individual results in a maximum density of 1 person/36 USF. Lobbies, conference rooms, and workstation spacing (private and common spaces, alike) should be carefully laid out and monitored. This may be as subtle as demarcating distances with colorful tape on the floor or a plexiglass screen positioned around a reception desk. All shared surfaces require thorough sterilization between use.

Thermal scanners are effective in detecting people who have developed a fever - a central symptom of COVID-19 infection9. Identifying and quarantining those presenting with an elevated temperature is a productive way to prevent the spread of disease – COVID-19 or other illnesses. Many hospitals and offices across the country have already mandated this practice at designated entry points into a facility. However, because it takes between two and ten days before people who are infected with COVID-19 to develop a fever, this preventative method still allows for transmission of the disease within the ten-day window.10 Ideally, temperature checks are performed directly before or immediately after entry into a facility vestibule. Corporations and building management companies are also asking employees and visitors to sign waivers attesting to their travel, health, and family exposure to ensure proper quarantining procedures are adhered. Once COVID-19 instant tests are more widely available, these checkpoints may act as testing centers for workers and visitors, a factor to consider when planning and installing a station.

Infectious Disease Preparedness and Response Plan

The Occupational Safety and Health Administration (OSHA) recommends that each business develop an Infectious Disease Preparedness and Response Plan to understand key industry risk factors that may make employees more sensitive to infection (e.g., over 65 in age; presence of chronic medical conditions, immunocompromising conditions; pregnancy) and put measures into place to protect the health of these at-risk workers.11

Classifying Worker Exposure

Another planning tool designed by OSHA divides job tasks into four risk exposure levels: ‘very high, high, medium, and low’ risk. ‘Very high’ and ‘high’ are associated with roles in healthcare – nurses, physicians, morgue workers – as they treat infected patients. The traditional office worker falls into the ‘medium’ risk category. However, because the amount of exposure to COVID-19 is associated with increased virulence, some office workers with public facing roles (i.e. busy receptionist or store clerk) may rise to the level of ‘high’ and warrant additional precautionary protective measures, including enhanced personal protection equipment or temporary physical barriers 12.

In an effort to minimize the number of shared spaces and de-densify funnel points, many companies are enacting new circulation plans and schedules for employees. Departments are assigned separate parking areas, entrances, stairwells, and bathrooms to minimize cross contamination of people and surfaces. Just as our groceries have planned morning hours for senior citizens, a company headquarters may have assigned waves of arrival and departure times for employees to stagger utilization of the building.13

Personal protection equipment (PPE) ranges in sophistication with the most protective material saved for front line healthcare workers – or those in the OSHA ‘high’ and ‘very high’-risk categories. For the traditional office worker of ‘medium’ risk, the CDC recommends the use of cloth face coverings to both slow the spread of the virus and help asymptomatic or presymptomatic people from unknowingly transmitting it to others. Many states have adopted the recommended use of cloth face coverings into their COVID-19 response mandates. Employees returning to work should be expected to use cloth face covering. These materials may be provided by the company to all employees to ease the burden of expectation. However, with strained supply chains, creative solutions for sourcing masks may be necessary.14 For employees identified as ‘at-risk’ during development of the OSHA Infectious Disease Preparedness and Response Plan or for employees in the OSHA Risk Exposure Levels of ‘very high’ or ‘high’, PPE requirements will be more stringent. For these groups, companies are to refer to the CDC guidelines for higher risk employees.

Strategies for Infection Control: Policy

Social Distancing

Work from Home

De-densification

Preparedness & Classifying Choreographed Response Plan Worker Exposure Circulation

Temperature & Travel History

PPE

Elevar Design Group Regan Henry, Greg Otis, Tony Lozier, Dara Baldridge

Strategies for Infection Control: Operations & Maintenance

Custodial Services

Minimize Touch Points

Timed Handwashing

Operations & Maintenance Custodial Services

The Center for Disease Control (CDC) has issued clear directives for effective cleaning methods and products, enhanced frequency of cleaning throughout the workday, and focused sterilization overnight. New cleaning operations may include: • Provide cleaning supplies and cleaning protocols for all staff • Clean and disinfect frequently touched objects and surfaces such as workstations, keyboards, telephones, handrails, and doorknobs regularly • Adopt electrostatic spraying technology to more thoroughly disinfect surfaces • Remove or prevent the use of fabric, porous, or hard to clean surfaces • Provide tissues and no-touch trash receptacles for all staff and customers – empty and clean receptacles often These enhanced cleaning protocols require increased staff, more exacting supplies, and enhanced equipment. One sterilization technique that has profound impact involves UVC or germicidal light emitting systems. Today, UVC-emitting robots are cleaning floors in hospitals and operating rooms, while banks use the powerful germicidal light to disinfect money. Enhanced cleaning equipment such as UV-C emitting systems or electrostatic spraying technology may be a worthwhile investment in high-risk environments.

Minimize Touch Points

While many modern restrooms have motion sensor fixtures, today the importance of eliminating shared touch points is paramount. Consider removing unnecessary high-risk touch points and installing products designed to minimize cross contamination of users. • Remove unnecessary doors where possible to have barrierless transitions between rooms • Retrofit fixtures (i.e. lights, toilets, faucets, soap/sanitizer dispensers, drinking fountains) to be motion sensor or foot enabled • Install StepNPull adaptations to doors to enable opening a door with a shoe instead of hand

Strategies for Infection Control in the Workplace, A Checklist April 28, 2020

Hand Sanitation

Decommission Jet Air Dryers

Physical Barriers

• Reverse door swings or retrofit doors with multi-directional swing hinges • Install hold open hardware to keep required doors in an open position unless triggered by alarm While not all touch points are avoidable, the dangers may be mitigated by paying careful attention to common circulation patterns and addressing high risk surfaces with regular and thorough cleaning protocols.

Encourage Timed Handwashing

Print and post copies of the CDC’s, “Life is Better with Clean Hands” posters to raise awareness and accountability for routine handwashing.15 Post the CDC’s guidelines for handwashing above the faucet on the restroom mirror next to a passage or song that takes 20 seconds to read or sing.16 When expectations are clearly outlined and unavoidable they are harder to ignore.

Provide Hand Sanitation Centers

Install hand sanitation centers at high frequency locations and high-risk touch points. The hand sanitizer should be at least 60% alcohol and applied per CDC guidelines: covering all surfaces and rubbed in until hands feel dry (approximately 20 seconds). Begin a public health campaign by posting guidelines and promotional materials to encourage frequent and effective use of hand sanitizer.17

Decommission Jet Air Dryers

A study presented in the Journal of Applied Microbiology addressed the efficacy of hand drying with paper towels versus jet air or warm air drying. The findings were conclusive: jet air drying resulted in significantly more viral contamination. The average number of virus particles scattered by the jet air dryer were 2219; warm air dryer, 34; and paper towel, 2. Jet air dryers launch moisture, including viral droplets, back at the hand and into the surrounding air, contaminating the hands and air in the restroom for anyone nearby.18 Removing or decommissioning jet air drying in bathrooms and installing paper towel dispensers is recommended during the pandemic.

Install Physical Barriers

At high frequency locations, such as a reception desk or checkout counter, installing clear plastic surrounds may be appropriate to protect both parties against contamination. Where face to face interaction is required and social distance requirements unachievable these dividers are critical to protecting public facing employees. Just as a sneeze guard at the buffet protects the food from contamination, a plexiglass divider will prohibit contagions from crossing into ones’ personal space.

Engineering Controls Increased Outside Air

As we learned in science class, “the solution to pollution is dilution,” buildings that achieve higher ventilation rates will reduce risk. The more fresh air that comes into a space, the less likely stale and infected air is able to settle. Whenever possible Heating, Ventilation and Air Conditioning (HVAC) systems should be modified to increased fresh air delivery – the more the better. While bringing in new air may test the limits of a heating and air conditioning system, the optimum balance is to provide a maximum volume of fresh air while maintaining the ability of a HVAC system to keep a comfortable temperature. Whenever possible, opening operable windows (and encouraging circulation with fan) to refresh inside air is encouraged. The World Health Organization (WHO) has established guidelines for how to appropriately naturally ventilate in healthcare facilities - a useful resource should this strategy be possible.19

Increased Air Exchange Rates

The COVID-19 virus will circulate in unfiltered air conditioning systems for several hours; however, aerosol droplets tend to settle on surfaces faster in disturbed air.20 In addition to increased outside air, research suggests increasing the air exchange rates helps circulate air and move dangerous microbes. In the same way operating rooms or clean rooms are pressure positive – increasing forced air creates a similar dynamic by pushing air through the space. Outside air intake must be increased at the air handling unit and in the system by which air is distributed throughout the space. Many Variable Air Volume (VAVs) HVAC systems operate at 60% of capacity. Adjusting the system to operate closer to 80% of capacity allows for greater replacement and circulation of air in a given time period. The ability to retrofit existing systems is dependent upon the existing equipment and programming capabilities.

element of an HVAC system, but difficult to add to an existing HVAC system. When carefully selected and designed, single-space highefficiency filtration units (ceiling mounted or portable) may be highly effective in decreasing concentrations of infectious aerosols in a single space.21

UV-C Light

UV-C or germicidal light is a technology being used to sterilize hospital operating rooms, planes, and subway trains. These shorter, stronger light waves can penetrate deep into the microbe destroying genetic material – whether in humans or viral particles - sterilizing the air and surfaces exposed to the light. Ultraviolet light can be retrofit into an existing Air Handing Unit (AHU). This initial expense is minimal, yet it provides the following benefit: • Ensures sterilized air is circulating through the system • Lower cases of airborne illnesses – healthier building occupants • UV-C light kills microbials growing on coils or within ducts – improving the output volume • Cleaner systems equate to decreased energy required for AHU performance and lowered costs • Lower maintenance costs due to cleaner coils and ducts22 The World Health Organization cautions that while this technology will kill a virus, it does not discriminate between good and bad cells and has deleterious health consequences on our bodies (especially eyes) in seconds of exposure. For this reason, only highly trained personnel should work with this type of product. Because of its revolutionizing sterilization ability, UV-C light systems and installers are in very high demand globally.

Strategies for Infection Control: Engineering Controls

HEPA Filters

The most sophisticated High Efficiency Particulate Arrestance (HEPA) filters capture microbes, dust, and particulates. Commonly used in critical care environments within healthcare facilities, HEPA filters are 99.97 percent effective at trapping particles down to 0.3 microns in size. Thus, HEPA filters can capture the COVID-19 virus contained within the aerosol particles, which last longer – but not the COVID-19 microbes themselves. Even HEPA filters that have been tested in the laboratory with viruses have some level of virus penetration. The addition of a HEPA filtration will cause static buildup in a system otherwise not designed for it. Additional static pressure can significantly increase fan energy requirements, causing a dramatic decrease the air exchange rates and decreased fresh air into the space - a tradeoff that must be measured on a case by case basis. HEPA filters are effective when designed as an original

Increased Outside Air

Increased Air Exchange Rates

UV-C Light

HEPA Filters

50-60% Relative Humidity

Elevar Design Group Regan Henry, Greg Otis, Tony Lozier, Dara Baldridge

Maintaining 50-60% Relative Humidity

Relative Humidity (RH) is shown to affect the viability of a virus in aerosols by controlling the amount of water retained, the size of an aerosol, the concentrations of solutes, and its pH.23 Viruses that require acidification before fusion, such as SARS coronavirus, are less stable at 50 to 90% RH than at RHs outside this range. However, droplets containing the virus can live longer on surfaces in high humidity conditions. Traditional viruses are least viable in that range of 40 and 60 percent RH. When RH levels fall below 35 percent viruses thrive in the body because the respiratory system is less able to clear infection.24 Research suggests a target of 50% to 60% indoor RH is ideal for destabilizing the COVID-19 virus and maintaining a healthy immune response in employees.

Operating and installing humidifiers in an AHU is expensive. Humidifier distribution systems need a lot of distance on their inlet and outlet, for putting moisture into the air and the moisture being absorbed by the air before any obstruction forced the water droplets out of the air. The value of such a system retrofit would need to be evaluated on a case by case basis.

Conclusion: In the wake of the COVID-19 global health crisis, concern for workplace safety is at unprecedented levels. Employees expect new policies and more stringent actions to be taken to address their wellbeing and prevent the spread of disease in their community. Facility Managers will play a key role in keeping inhabitants healthy and protected. This report examines many ways the workplace may be adapted through policy, operations and maintenance, and engineering controls, to better safeguard employees from infectious disease.

Notes 1 World Health Organization (2020), “Naming the coronavirus disease (COVID-19) and the virus that causes it,” 2020, https://www. who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/naming-the-coronavirus-disease-(covid-2019)-and-the-virusthat-causes-it 2 Ana Sandoiu, “Coronavirus may spread faster than WHO estimate,” Medical News Today, February 18, 2020, https://www. medicalnewstoday.com/articles/coronavirus-may-spread-faster-than-who-estimate.html 3 Joseph Eisenberg, “R0: How scientists quantify the intensity of an outbreak like coronavirus and predict the pandemic’s spread,” The Conversation, February 5, 2020, Updated March 27, 2020, https://theconversation.com/r0-how-scientists-quantify-the-intensity-of-anoutbreak-like-coronavirus-and-predict-the-pandemics-spread-130777 4 Dr. van Doremalen, Mr. Bushmaker, Mr. Morris, et.al., “Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1,” New England Journal of Medicine 382 (March 2020):1564-1567. DOI: 10.1056/NEJMc2004973 5 Maria Taylor, “Coronavirus Prompts Response in HVAC Industry,” The News, March 9,2020, https://www.achrnews.com/ articles/142808-coronavirus-prompts-response-in-hvac-industry.html 6 Kate Lister, “Latest Work-at-Home/Telecommuting/Mobile Work/Remote Work Statistics,” March 2020, https:// globalworkplaceanalytics.com/telecommuting-statistics.html 7 Karen Master, “U.S. professionals drawn to cities for career success now want out,” Citrix, April 30, 2019, https://www.citrix.com/ news/announcements/may-2019/professionals-drawn-to-cities-for-career-success-now-want-out.html 8 Owl Labs, “State of Remote Work,” 2019, https://www.owllabs.com/state-of-remote-work/2019.pdf 9 World Health Organization (2020), “Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19),” 16-24 February 2020, https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf 10 World Health Organization (2020), “Coronavirus disease (COVID-19) advice for the public: Myth busters,” https://www.who.int/ emergencies/diseases/novel-coronavirus-2019/advice-for-public/myth-busters.html

Strategies for Infection Control in the Workplace, A Checklist April 28, 2020

11 U.S. Department of Labor Occupational Safety and Health Administration, “Guidance on Preparing Workplaces for COVID-19,” OSHA 3990-03, 2020, https://www.osha.gov/Publications/OSHA3990.pdf 12 Siddhartha Mukherjee, “How Does the Coronavirus Behave Inside a Patient?” The New Yorker, March 26, 2020, https://www. newyorker.com/magazine/2020/04/06/how-does-the-coronavirus-behave-inside-a-patient 13 Cushman & Wakefield, 6 Feet Office, 2020, https://www.cushmanwakefield.com/en/netherlands/six-feet-office 14 Centers for Disease Control and Prevention, “Coronavirus Disease: Situation Summary,” April 19, 2020, https://www.cdc.gov/ coronavirus/2019-ncov/cases-updates/summary.html 15 Centers for Disease Control and Prevention, “Life is Better with Clean Hands,” April 13, 2020, https://www.cdc.gov/handwashing/ campaign.html 16 Centers for Disease Control and Prevention, “When and How to Wash Your Hands,” April 2, 2020, https://www.cdc.gov/ handwashing/when-how-handwashing.html 17 Centers for Disease Control and Prevention, “Hand Sanitizer Use Out and About” April 13, 2020, https://www.cdc.gov/ handwashing/hand-sanitizer-use.html 18 Kimmitt, P.T. & Redway, K.F. (2016). Evolution of the potential for virus dispersal during hand drying: a comparison of three methods. Journal of Applied Microbiology. 120,478-486 19 Atkinson J., Y. Chartier, C.L. Pessoa-Silva, P. Jensen, and W.H. Seto. 2009. Natural Ventilation for Infection Control in Health-Care Settings. Geneva: World Health Organization. www.who.int/water_sanitation_health/publications/natural_ventilation/en. 20 Richard Gray, “Covid-19: How long does the coronavirus last on surfaces?” March 17,2020, https://www.bbc.com/future/ article/20200317-covid-19-how-long-does-the-coronavirus-last-on-surfaces 21 American Society of Heating and Air-Conditioning Engineers (ASHRAE), “Position Document on Infectious Aerosols,” April 14, 2020, https://www.ashrae.org/file%20library/about/position%20documents/pd_infectiousaerosols_2020.pdf 22 Firouz Keikavoisi, “UVC: Florida Hospital Puts HVAC Maintenance Under A New Light,” Engineering Systems Magazine, February 24, 2004, 1245 23 Yang W, Marr LC. “Mechanisms by which ambient humidity may affect viruses in aerosols,” Appl Environ Microbiol. 2012;78(19):6781–6788. doi:10.1128/AEM.01658-12 24 Ana Sandoiu, “How humidity may affect COVID-19 outcome,” Medical News Today, April 2, 2020, https://www.medicalnewstoday. com/articles/how-humidity-may-affect-covid-19-outcome.html

Icon Credit “Barrier” by Vadim Solomakhin, from thenounproject.com “Circulation” by Timofey Rostilov, from thenounproject.com “Clean” by Vadim Solomakhin, from thenounproject.com “Cleaning” by Flatart, from thenounproject.com “Constructions” by Komkrit Noenpoempisut, from thenounproject.com “Covid-19” icon by OCHA Visual, from thenounproject.com “Filter” by Dika Darma, from thenounproject.com “Hand Dryer” by Manthana Chaiwong, from thenounproject.com “Hand Sanitizer” by Andi Nur Abdillah, from thenounproject.com “Health Care” by Jeehan@design, from thenounproject.com “Light” by iconeu, from thenounproject.com “Maintenance” by Vectors Market, from thenounproject.com “Man” by Gan Khoon Lay, from thenounproject.com “Medical Mask” by myiconfinder, from thenounproject.com “Percentage sign, Humidity” by icon 54, from thenounproject.com “Policy” by Adrien Coquet, from thenounproject.com “Risks” by Ralf Schmitzer, from thenounproject.com “Social Distancing” by OCHA Visual, from thenounproject.com “Thermometer” by nopixel, from thenounproject.com “Tools” by tezar tantular, from thenounproject.com “Touch” by Adrien Coquet, from thenounproject.com “Vent” by Andrejs Kirma, from thenounproject.com “Work from Home” by Icon Track, from thenounproject.com Copyright © Elevar Design Group All Rights Reserved

Elevar Design Group Regan Henry, Greg Otis, Tony Lozier, Dara Baldridge