To improve TB infection prevention and
control (IPC) in health facilities, CO₂ monitors are installed in to
monitor carbon dioxide levels as a proxy for TB transmission risk. Hospital waiting
rooms, outpatient clinics, emergency departments and inpatient wards are often
ventilated at levels well below those recommended for the control of TB transmission.
CO₂ monitors are utilised to
evaluate environmental controls and ensure efficacy of infection control
measures in health facilities real-time. Warning alarms prompt the healthcare
workers to improve ventilation in waiting areas through opening windows or
moving people to an outdoor area.
Through a partnership with the USAID Tuberculosis South Africa Project, the Council for Scientific and Industrial Research (CSIR) has developed GPRS-enabled CO₂ monitors that can serve as a real-time alarm for the management and operational response of indoor areas with high potential for airborne disease transmission. The differential between indoor and outdoor CO₂ levels can be measured and used to estimate the ratio of rebreathed air in a space and thereby the risk of airborne disease transmission. The monitor can also be used as a simple data logger to record indoor air quality metrics such as CO₂, temperature and humidity.
Rationale and Relevance to TB Infection Prevention and Control
CO₂ is produced by people when they breathe. Each exhaled breath by an average adult contains 35,000 to 50,000 parts per million (ppm) of CO₂ – 100 times that of the typical concentration in the outside air. By measuring the indoor CO₂ concentration in different rooms of a health facility as a proxy, the ratio of rebreathed air can be used to estimate the risk of airborne disease transmission in a given space. CO₂ Threshold values can be established such that less than 1 transmission occurs for each exposure event. By setting such CO₂ threshold values, health care workers can be alerted when CO₂ concentrations indicate epidemic levels of indoor transmission. Action can then be taken to either increase ventilation or to remove people from the space.
Benefits and Advantages
The use of CO₂ monitors confers numerous benefits and advantages as part of a complete, holistic IPC strategy. These benefits include:
Testimonials from Health Care Workers
“It’s effective, serve as an indicator to observe the area and check if the department is adhering to IPC policy ad practices like open window policy”. “We are being notified daily with SMS messages on personal mobile numbers and request from the technical guys that we would like to get SMS messages within reasonable working hours. So far SMS are alarming in the middle of the night which makes it impossible to get a good night sleep.” |
Guidelines for Monitor Placement
The following guidelines are used for placing monitors in the facilities:
Data Collection
CO₂ monitors collect CO₂ concentration (in parts per million [ppm]), temperature, relative humidity and battery
voltage data in real time (the average of 60 readings every 15 minutes). These
readings are collected and stored locally on an SD card, and are subsequently sent
via cellular network to a secure, centralized server for storage and analysis. CO₂ monitors require an external power source for operation and thus
collect voltage to understand whether a power outage occurred during the day.
CO₂ Alerts and Alarms
The CO₂ monitors can be configured
to have two thresholds: an alert limit (Typically 550 ppm or more) and an alarm
at 1100 specification
(OOS) reading to health care
workers via automatic SMS/text message, prompting them to decant those areas that are
congested or poorly ventilated. When the average CO₂ level exceeds the alert limit for at least one hour, the device triggers
an SMS alarm to health care workers. If the average CO₂ level
exceeds the alarm level for any 15-minute period, the device triggers an SMS
alarm to health care workers.
SMS alerts and alarms contain the location
of the device, time, average CO₂ level, minimum CO₂ level, maximum CO₂ level, temperature, Risk Index (%) and battery
charge level. Each device sends SMS alerts individually to one IPC/FAST
champion in the facility. IPC/FAST champions are coached to recognize that when
the minimum CO₂ level is exceeded, they must alert the health care workers to either
improve ventilation or decant the affected areas.
On-Demand Data Dashboards
The on-demand dashboard through the IPConnect suite of applications allow facility managers, program managers and other key stakeholders to look both at real time CO₂ data and at historical trends to facilitate immediate action planning for improved IPC over time.
Data Analysis Procedures
Initial data analysis procedures include
examining the number of OOS events in a given day, the % of time in a day
during which the CO₂ monitors recorded an OOS event, and the R0e% in
a given day (that is, the probability of TB transmission given the CO₂ concentration).
Average OOS Events
This value is calculated by examining the
number of times a given CO₂ monitor registered an OOS (typically above
550 ppm) value and taking the sum for the day. Currently this value is averaged
over the quarter at the individual CO₂ monitor level. Future work in
IPConnect will allow the user to select the duration of time over which to
average the value (i.e. OOS events in a day, week or month).
Daily OOS Hours (%)
This value is calculated by examining, for
each time a CO₂ monitor registers an OOS (above 550 ppm) value, the
time the monitor continues to register OOS values. The total time a given
monitor records OOS values for the given day is summed and taken as a
percentage of the entire day. This value is currently averaged over the quarter
at the individual CO₂ monitor level. Future work in IPConnect will
allow the user to select the duration of time over which to average the value
(i.e. average OOS hours in the given day, week or month).
R0e
This value, the environmental reproduction
number, is described in detail by van Reenen in “CO₂ Alarm Limit for
Airborne Disease Transmission” (2017). In summary, this value represents the
number of secondary cases (in this case, of TB) derived from a primary case (of
TB). If this value is less than one, the disease-free equilibrium is maintained,
and transmission would not occur. R0e values above one, then, suggest onward TB
transmission. To calculate the R0e the number of room occupants is required.
For this analysis, the number of room occupants is assumed to be 100 and the
number of infectors to be 1 in 100. This allows the R0e to represent the
percentage of transmission events (R0e%) per number of exposed room occupants.
It is important to caution here that transmission events and progression to TB
disease should not be conflated. The R0e% reported therefore remains useful as
index of risk alone until a susceptibility factor can be introduced. For this
analysis, an environment with R0e% of 1.0% or greater is considered to
contribute towards outbreak conditions.