Senior Living Facilities: Ventilation and respiratory health study by Institute for Health in the Built Environment

Senior Living Facilities

Ventilation and respiratory health study

Development of a ventilation system assessment (VSAI) toolkit for the reduction of respiratory disease in senior living facilities

Prepared for Oregon Health Authority (OHA)

Prepared by

Institute for Health in the Built Environment (IHBE)

College of Design

School of Architecture & Environment

5249 University of Oregon Eugene, Oregon

Research Team

Mark Fretz, Co-Director, IHBE, Assistant Professor (PI)

Dale Northcutt, Senior Research Assistant, ESBL

Alen Mahic, Research Associate, ESBL

Rowan Bullock, Graduate Researcher, BioBE

Laura Jacek, Office Manager, ESBL

Jason Stenson, Senior Research Assistant, ESBL

Gwynne Mhuireach, Research Assistant Professor, BioBE, ESBL

Project Number

Oregon Health Authority Grant Agreement Number 170466

University of Oregon EPCS 31966

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01 INTRODUCTION & BACKGROUND

Building management techniques like HEPA filters and mechanical and non-mechanical ventilation have each proven effective at diluting and removing the viral load in a room thereby mitigating the risk of COVID-19 infection and spread inside buildings. Medical facilities and long-term care centers have an interest in understanding how different building aerosol management techniques impact the presence of SARS-CoV-2 in the air and whether viral particles can spread outside of a patient's room during regular care activity.

The University of Oregon’s Institute for Health in the Built Environment (IHBE) has been working in collaboration with the Oregon Health Authority (OHA) to develop a Ventilation System Assessment and Improvement (VSAI) Toolkit for use by residential care facility staff and administrators to reduce the risk of respiratory disease transmission in buildings. The Toolkit is intended to give building users and operators an overview of how most heating, ventilation, and air conditioning systems function in residential settings, as well as practical and actionable strategies to improve their operation.

As part of the development of the VSAI Toolkit, University of Oregon (UO) researchers evaluated its ease of use, applicability, and effectiveness in facilities that request a consult. UO researchers accompanied OHA infection prevention staff for 10 total site visits during which air sampling and environmental data was collected.

Our team completed development of the VSAI Toolkit as part of the first phase of this study. We then disseminated it across 10 facilities in the state of Oregon via on-site consultations as the second phase of the study. As such, this report focuses on findings from the second phase, which primarily focuses on testing and gathering feedback on the usefulness of the Toolkit from facilities managers and/or staff at each site.

Primary goals of this study

1. Develop a ventilation system assessment and improvement (VSAI) toolkit in collaboration with Oregon State University (OSU) and Oregon Health Authority (OHA) Healthcare-Associated Infections (HAI) Program. (Phase 1)

2. Pilot the VSAI toolkit in collaboration with HAI Program across ten (10) on-site ventilation consultations. (Phase 2)

3. Conduct follow up with facilities to ascertain which recommendations have been implemented, collecting facility specific feedback relating to the measures recommended, including applicability of recommendations, barriers to implementation, and any issues after implementation. (Phase 2)

02 METHODS

The UO-IHBE team visited 10 residential care facilities to assess HVAC systems and perform indoor air sampling. HVAC assessment followed the Ventilation Toolkit and included: presence and characteristics of a ducted or in-room mechanical ventilation system; use of natural or passive ventilation strategies; whether the mechanical ventilation system isolates rooms or mixes air from multiple spaces; presence of filtration, in the mechanical system or standalone; and location of air intake and supply, confirmation of airflow, and frequency of maintenance.

Approximately two weeks after each site visit, we attempted to follow-up with facilities managers and/or staff from each site to gather feedback on their experience using the Toolkit. This was done remotely via a brief phone interview.

The presence of SARS-CoV-2 in the indoor air was assessed using Thermo Scientific AerosolSense air samplers (up to 10 areas per site) and HOBO monitors were used to assess relative humidity, temperature, and indoor CO2 levels as a proxy for ventilation. Environmental monitors were co-located with active air samplers and devices were placed at table height.

Air was sampled for at least one hour, ideally two or more. The air samplers capture aerosolized biological particulates such as bacteria and viruses.

After the sampling period, the individual samples were placed in DNA/RNA Shield and transported to the University of Oregon laboratory for viral RNA extraction and quantitative PCR to detect the presence of SARS-CoV-2 virus.

Sample results were either positive (SARSCoV-2 was detected), negative (SARS-CoV-2 was not detected), or inconclusive (SARSCoV-2 was detected, but not in sufficient quantities for certainty). A small number of samples are unknown, due to a failure in laboratory quality control, which may have resulted from low sample quality or contamination.

The ventilation toolkit was developed by the UO-IHBE team in collaboration with OHA. This tool was designed to help facilities managers improve indoor air circulation in their buildings.

The toolkit was distributed to facilities managers/administrators before, during, and, in some cases, after each of the ten site visits. Attempts were then made to schedule and conduct brief follow-up interviews to see if the ventilation toolkit was used to implement any changes in their facilities, and to gather feedback on its usefulness. The questions included the following:

Q1: Did you have a chance to look at or use the toolkit?

Q2a: Did you apply the Toolkit?

Q2b: Did you make any HVAC upgrades, or do you have any planned in the future?

Q3a: What are your barriers to implementing changes, if any?

Q3b: Is it a matter of lacking funding and/or expertise?

Q4: Could you rate the usefulness of the toolkit on a scale 1-10? (1 – not useful at all; 10 –extremely useful)

Q5a: Was the toolkit clear and easy to use?

Q5b: Was there anything that you found unclear or difficult to implement?

Q6: Any recommended revisions from your perspective?

Q7: Do you have any additional feedback? (Open-ended)

03 RESULTS & FINDINGS

Executive Summary

The following summary touches on some of the key findings of this study.

HVAC assessment

Overall, the facilities tended to vary in age, even on the same campus due to remodeling or additions. There was often a variety of HVAC system types, which included heat pumps, furnaces, and/or PTAC. Most also had local mechanical exhaust capabilities, generally a restroom ventilator under manual control by the resident. However, in some cases the exhaust did not seem to move air during our team's site visit.

The facilities managers were generally knowledgeable about air filters and timing in these systems, but some did have service contracts with third parties that performed filter maintenance and as such were less directly knowledgeable about their facility's systems efficiencies.

Air sampling and ventilation

In this study, CO2 and RH levels were not significantly associated with SARS-COV-2 presence.

However, qPCR results from sites with confirmed COVID cases indicated that, largely, viral particles were present outside of the rooms of infected residents.

Furthermore, several sites without confirmed cases demonstrated that viral particles were present, in 8/9 viable samples in one case. This may potentially indicate the presence of asymptomatic disease in these facilities.

Ventilation Toolkit feedback

The toolkit was well-received and said to be clear and easy to use, receiving aboveaverage marks from facilities managers and administrators. The average usefulness rating came out to 7.4 out of 10 (1 – not useful at all; 10 – extremely useful), with the reported primary uses of the Toolkit including:

• Air filter changes, upgrades to higher MERV rating, and planning for regular maintenance.

• Assistance in set-up of portable in-room filtration systems provided by OHA. Although some facilities may have staff conflicts related to noise, which at times results in the units being switched off or set to the lowest setting.

• Adjusting fan operating schedules to run 24/7 in hallways so as to utilize air filters regardless of whether the system is in heating or cooling mode.

• More frequent use of bathroom exhaust fans.

• Advising safety committee to open exterior side doors and windows in unoccupied rooms to take advantage of natural ventilation, outside periods where outdoor air may be a detriment (wildfire smoke, pollen, etc.).

Site 01 Existing mechanical systems

Site 01 is a medium-sized, skilled nursing rehabilitation center in Oregon with a total of 87 units.

The mechanical systems vary across the facility, and on-site observations confirmed the following:

• Radiant floor heating.

• Hot water convector. [1]

• Window PTAC with and without separate exhaust. [2]

• Split system. [3][4]

• Central air heating and cooling and heat pump[5], with possible supplemental gas heating.

• Corridor[7] and in-room[6] supply, and corridor and skylight returns[8].

• Central outdoor supply air that runs with the central HVAC. [9]

• Resident bathroom exhaust is controlled via manual switch that also controls the electric lights.

• Operable windows are available in most resident rooms.

• Resident room areas vary between 120ft2 and 240ft2 with a 9ft ceiling height.

Site 01

Indoor air

SARS-CoV-2 Air sampling

The first air sampler was deployed at 1:46PM and the last was collected at 5:54PM, which yielded a total of 10 samples from this site. Table 1 shows the reported status of this site, COVID positive at the time of the visit, along with the COVID status from the air sample test results: 9 positive, 0 negative, and 1 inconclusive.

Site 01

Site Status: COVID + COVID present in air samples

Positive Negative Inconclusive

9/10 0/10 1/10

Ventilation & air filtration

The average CO2 measurements remained relatively steady at 500ppm for the common areas, regardless of ventilation status, while the resident rooms varied between 520ppm and 620ppm with and without ventilation or HEPA filtration, respectively.

The overall relative humidity did not show significant changes, with resident rooms hovering at 45% while the common areas varied slightly between 46% and 48%.

The following page includes CO2 and relative humidity for each sample collected at this site. They are categorized relative to the SARS-CoV-2, ventilation, and HEPA filtration status.

Ventilation Toolkit feedback

Our team was unable to conduct a follow-up interview for this site.

Site 01 carbon dioxide (CO2) measurements all fell under 750 parts per million (ppm), within the limits for levels for healthy indoor air from The American Society of Heating, Refrigeration and Air Conditioning Engineers (ASHRAE).

Site 01 relative humidity (RH) measurements all fell within 30-50%, which is recommended by the Environmental Protection Agency (EPA) as the range that is most comfortable for indoor air.

Site 02 Existing mechanical systems

This site is a medium-sized skilled nursing facility located in Oregon and specializes in providing posthospital rehabilitation and long-term care services, catering to seniors with a variety of health care needs. The facility has a capacity of 136 licensed beds and offers 24-hour nursing care, personal assistance with daily activities, therapy services, and a range of other amenities aimed at ensuring a comfortable and supportive environment for its residents.

Mechanical systems

The mechanical systems vary across the facility, and on-site observations confirmed the following:

• An older South wing has two HVAC zones/systems that are generally under-slab floor supply to the resident units.

• The room returns are high on the corridor wall that is centrally ducted in the attic. [1][2]

• A thermostat is available in the hallway.

• The main HVAC is generally forced air with gas for heating, condenser for cooling, and outside air supply.

• System does not include a main exhaust in the loop.

• The return filter and the outdoor air filter are MERV 13 and replaced monthly. [3]

• Resident bathroom exhaust is controlled via manual switch that also controls the electric lights.

• Supplemental electric baseboards are included in the hallways. [4]

• The North wing uses primarily PTAC units at the windows for heating and cooling of the rooms. It appears to operate with outdoor air but our team was unable to verify for certain. [5]

• Roof top units are included on the roof. [6]

• Some select spaces are supplemented with heat pumps. [7]

• Portable HEPA air filters were running in the hallways during our visit, but our team was not able to verify filters or flow rate.

• Operable windows are available in resident rooms.

• Resident room areas were roughly 205ft2 with a 9ft ceiling.

Site 02

Indoor

air

Air sampling

The first air sampler was deployed at 10:43AM and the last air sampler was collected at 2:43PM, which yielded a total of 10 samples from this site. Table 1 shows the reported status of this site, COVID positive at the time of the visit, along with the COVID status from the air sample test results: 10 positive, 0 negative, and 0 inconclusive.

Site 02

Site Status: COVID + COVID present in air samples

Positive Negative Inconclusive 10/10 0/10 0/10

Ventilation & air filtration

The average CO2 measurements remained relatively steady at 840ppm for the common areas, regardless of ventilation status, while the resident rooms varied between 790ppm and 900ppm with and without ventilation or HEPA filtration, respectively.

The overall relative humidity did not show significant changes, varying slightly between 48% and 50%

The following page includes CO2 and relative humidity for each sample collected at this site. They are categorized relative to the SARS-CoV-2, ventilation, and HEPA filtration status.

Ventilation Toolkit feedback

Our team was unable to conduct a follow-up interview for this site.

Site 02 carbon dioxide (CO2) measurements all fell under 1000 parts per million (ppm), within the limits for levels for acceptable indoor air from The American Society of Heating, Refrigeration and Air Conditioning Engineers (ASHRAE).

Site 02 relative humidity (RH) measurements largely fell within 30-50%, which is recommended by the Environmental Protection Agency (EPA) as the range that is most comfortable for indoor air. All samples fell under the 60% maximum recommended RH level.

Site 03

Mechanical systems

The mechanical systems vary across the facility, and on-site observations confirmed the following:

• The north L-section built around 1966, slab floor with built-in duct work with return. This includes two mechanical rooms with two units, each serving four zones. [1][2]

• The south section was added in the 1980's with gas heating and electric chiller cooling with outdoor air makeup. This includes one system serving one zone.

• Filters varied from MERV 8 to 11 depending on location. [3]

• Returns were observed in the hallways, but it's possible there may be other returns in rooms our team could not visit. [4]

• Miscellaneous PTAC’s without fresh air.

• A few other task heaters/coolers.

• Kitchen exhaust is operated 24/7.

• Laundry exhaust, with outside air, two roof vents (~6-8” ID) open to outside.

• Ducts cleaned recently, as of site visit, and filters changed regularly every two to three months. [3]

• Operable windows are available in most resident rooms.

• Resident room areas were roughly 157ft2 with an 8.5ft ceiling.

Site 03

Indoor air

Air sampling

The first air sampler was deployed at 7:27AM and the last air sampler was collected at 11:12AM, which yielded a total of 10 samples from this site. The table below shows the reported status of this site, COVID positive at the time of the visit, along with the COVID status from the air sample test results: 1 positive, 9 negative, and 0 inconclusive.

Site 03

Site Status: COVID + COVID present in air samples

Positive Negative Inconclusive 1/10 9/10 0/10

Ventilation & air filtration

This site did not have data points for common areas that have ventilation or HEPA filtration.

The average CO2 measurements vary between 620ppm and 740ppm with and without ventilation or HEPA filtration, respectively, while the common areas without ventilation or HEPA filtration measured 710ppm.

The overall relative humidity did not show significant changes, varying slightly between 43% and 46%.

The following page includes CO2 and relative humidity for each sample collected at this site. They are categorized relative to the SARS-CoV-2, ventilation, and HEPA filtration status.

Ventilation Toolkit feedback

Question Response

Q1 Yes

Q2b No, but I did learn something.

Q2b Normal filter changes per maintenance schedule.

Q3a NA

Q3b NA

Q4 8

Q5a NA

Q5b No

Q6 No

Q7 NA

Site 03 carbon dioxide (CO2) measurements all fell under 1000 parts per million (ppm), within the limits for levels for acceptable indoor air from The American Society of Heating, Refrigeration and Air Conditioning Engineers (ASHRAE).

Site 03 relative humidity (RH) measurements all fell within 30-50%, which is recommended by the Environmental Protection Agency (EPA) as the range that is most comfortable for indoor air.

Site 04

Existing mechanical systems

Mechanical systems

The mechanical systems vary across the facility, with splits and ducted systems that vary by space type and floor for heating (gas & heat pump) and cooling (heat pump). On-site observations confirmed the following:

• There are three roof top regions--North, Central, and South--that serve the floors below each corresponding region. [1]

• The first floor includes splits in the North and South zones, with splits and ducted system in the Central zone.

• The second and third floors are roughly 60% splits[2] and 40% ducted on the North and South zones with splits and ducted in the Central zone. Documented supply and return grills on second and third floor hallways and common spaces. [3][4]

• Air filter MERV rating was unverified but most likely not HEPA. Filters are regularly maintained

alongside cleaning of units.

• Exhaust air systems include kitchen, laundry, and residential bathrooms. Bathroom fan and electric lighting are operated by the same switch.

• Operable windows are available in most resident rooms of the second and third floors. At the time of the visit a majority of doors and windows were closed but some residents did keep them open at least temporarily. [5][6]

• The first floor was not evaluated and includes primarily memory care, a gym, and a pool.

• Resident room areas were roughly 317ft2 with a ceiling height that varied between 8.5ft and 9.75ft ceiling.

Site 04

Indoor air

Air sampling

The first air sampler was deployed at 10:00AM and the last air sampler was collected at 1:46PM, which yielded a total of 10 samples from this site. The table below shows the reported status of this site, COVID positive at the time of the visit, along with the COVID status from the air sample test results: 10 positive, 0 negative, and 0 inconclusive.

Site 04

Site Status: COVID + COVID present in air samples

Positive Negative Inconclusive 10/10 0/10 0/10

Ventilation & air filtration

This site did not have data points for resident rooms that have ventilation or HEPA filtration.

The average CO2 measurements remained relatively steady at 610ppm for the common areas, regardless of ventilation or HEPA filtration status, while the resident rooms without ventilation or HEPA filtration measured 640ppm.

The overall relative humidity did not show significant changes, hovering at 35%.

The following page includes CO2 and relative humidity for each sample collected at this site. They are categorized relative to the SARS-CoV-2, ventilation, and HEPA filtration status.

Ventilation Toolkit feedback

Question Response

Q1 Yes

Q2b Talked at safety committee open the exterior side doors and windows in unoccupied rooms to take advantage of natural ventilation more except during periods where outdoor air may be a detriment (wildfire smoke, pollen).

Q2b Added 8 air scrubbers.

Q3a NA

Q3b NA

Q4 5

Q5a NA

Q5b Not bad but more aimed at people with less knowledge.

Q6 Add more suggestions of things to do.

Q7 NA

Sheet1

Site 04 carbon dioxide (CO2) measurements all fell under 750 parts per million (ppm), within the limits for levels for healthy indoor air from The American Society of Heating, Refrigeration and Air Conditioning Engineers (ASHRAE).

Site 04 relative humidity (RH) measurements all fell within 30-50%, which is recommended by the Environmental Protection Agency (EPA) as the range that is most comfortable for indoor air.

Site 05 Existing mechanical systems

Mechanical systems

The mechanical systems vary across the facility, and on-site observations confirmed the following:

• Facility is served by ducted systems that cover corridors, kitchen, dining, lobby, and multipurpose spaces with gas-fired heating[1] and electric cooling[2].

• Pleated filters are mainly MERV8[3] but a couple were found to be MERV 10[4].

• There is a unit in the attic that has heating, cooling, and filters but didn’t access that mainly covers kitchen/common area.

• Kitchen exhaust is operated 24/7. [5]

• Resident rooms are equipped window PTAC units without outside air capability. [6][7]

• Resident bathroom exhaust is switched separately from the electric lighting with no timer.

• Resident windows are fully operable (without a 3” governor)[7]. While some residents kept their

windows open, most kept their windows and doors closed.

• New portable HEPA filters were delivered via OHA. They have been deployed and were running in the facility prior to our team's arrival on-site. This included one in each hallway, two in the dining area, one in the lobby, and one in the lounge. Generally good coverage for this facility. They were initially set to low speed, UV on, and child locked. They tended to crowd perimeter walls leaving less than recommended ventilation access but were kept clear of the resident and staff circulation corridors.

• There is a misting system (Viking Pure) that is used once a day, twice during outbreaks. This system resembled a backpack or push unit that serves the hallways/common areas. Information on the model, solution, or settings were unavailable.

• Resident room areas were roughly 233ft2 with an 8ft ceiling height.

Site 05

Indoor air

Air sampling

The first air sampler was deployed at 9:48AM and the last air sampler was collected at 1:33PM, which yielded a total of 10 samples from this site. The table below shows the reported status of this site, COVID negative at the time of the visit, along with the COVID status from the air sample test results: 7 positive, 0 negative, and 1 inconclusive. (2 samples failed lab QC)

Site 05

Site Status: COVIDCOVID present in air samples

Positive Negative Inconclusive 7/8 0 1/8

Note: two samples failed quality control and have been excluded

Ventilation & air filtration

This site did not have data points for resident rooms that have ventilation or HEPA filtration.

The average CO2 measurements vary between 560ppm and 530ppm in the common areas with and without ventilation or HEPA filtration, respectively, while the resident rooms without ventilation or HEPA filtration measured 610ppm.

The overall relative humidity did not show significant changes, varying slightly between 42% and 43%.

The following page includes CO2 and relative humidity for each sample collected at this site. They are categorized relative to the SARS-CoV-2, ventilation, and HEPA filtration status.

Ventilation Toolkit feedback

Question Response

Q1 Yes

Q2b Will order higher MERV filters once stock is depleted. Now that the weather is nicer turning bathroom vents on more, cracking windows for ventilation, running AC fans in the halls 24/7 to utilize filters rather than only when heating or cooling.

Q2b Utilize higher MERV filters.

Q3a Not too many barriers, just need to watch the filter budget.

Q3b NA

Q4 8

Q5a It was clear.

Q5b NA

Q6 No

Q7 When will the results of the study be available? I said probably realistically a couple months out.

Sheet1

Site 05 carbon dioxide (CO2) measurements all fell under 750 parts per million (ppm), within the limits for levels for healthy indoor air from The American Society of Heating, Refrigeration and Air Conditioning Engineers (ASHRAE).

Site 05 relative humidity (RH) measurements all fell within 30-50%, which is recommended by the Environmental Protection Agency (EPA) as the range that is most comfortable for indoor air.

Site 06

Existing mechanical systems

Mechanical systems

The mechanical systems vary across the facility, and on-site observations confirmed the following:

• Facility includes ducted systems that serve hallways/common spaces with natural gas heating and evaporator cooling. [1][2][3]

• Most other spaces have been converted to split heat pump with multiple heads (4) per outdoor unit[4][5]. There is duct work and grills remaining in the ceiling/walls that are not used in these spaces. There is also an attached modular unit with a Baird unit at both ends. [6]

• Pleated filters are mainly MERV10.

• Kitchen exhaust is operated 24/7.

• Resident bathroom exhaust is controlled via manual switch that also controls the electric lights

and was observed to be off for the units that were accessible.

• Operable windows are available in most resident rooms.

• This facility is a mix of different constructions from 1948 when it used to be an old hospital, to 1977, to 1995 and some remodeling. There are areas where skylights seem to have been boarded up for reasons unknown[7].

• This facility has a misting peroxide fogging system that is used as needed but not regularly. However, this equipment was not evaluated during the site visit.

• Resident room areas vary between 216ft2 and 302ft2 with a ceiling height that varies between 7.5ft and 8.5ft.

Site 06

Indoor air

Air sampling

The first air sampler was deployed at 10:45AM and the last air sampler was collected at 2:09PM, which yielded a total of 10 samples from this site. The table below shows the reported status of this site, COVID negative at the time of the visit, along with the COVID status from the air sample test results: 1 positive, 4 negative, and 4 inconclusive. (1 sample failed lab QC)

Site 06

Site Status: COVIDCOVID present in air samples

Positive Negative Inconclusive 1/9 4/9 4/9

Note: one sample failed quality control and has been excluded

Ventilation & air filtration

This site did not have data points for common areas that have ventilation or HEPA filtration.

The average CO2 measurements vary between 680ppm and 640ppm in the resident rooms with and without ventilation or HEPA filtration, respectively, while the common areas without ventilation or HEPA filtration measured 640ppm.

The overall relative humidity did not show significant changes, varying slightly between 46% and 49%.

The following page includes CO2 and relative humidity for each sample collected at this site. They are categorized relative to the SARS-CoV-2, ventilation, and HEPA filtration status.

Ventilation Toolkit feedback

Question Response

Q1 Yes

Q2b No we are pretty well good since we have the higher MERV, HEPA units, and restrooms on exhaust already.

Q2b No

Q3a Budget is probably one, window operation interfering with thermostat, but in general doing well.

Q3b NA

Q4 8

Q5a It was good and maybe more effective at other facilities.

Q5b NA

Q6 Not necessarily, but it does give a heads up but not financial implications.

Q7 When will the results of the study be available? I said probably realistically a couple months out.

Sheet1

Sample Number

No Window Ventilation or HEPA Has HEPA Only

QC Failure

Inconclusive SARS−CoV−2 Result

Negative for SARS−CoV−2

Positive for SARS−CoV−2

Site 06 carbon dioxide (CO2) measurements all fell under 750 parts per million (ppm), within the limits for levels for healthy indoor air from The American Society of Heating, Refrigeration and Air Conditioning Engineers (ASHRAE).

Sample Number

No Window Ventilation or HEPA

Has HEPA Only

QC Failure

Inconclusive SARS−CoV−2 Result

Negative for SARS−CoV−2

Positive for SARS−CoV−2

Site 06 relative humidity (RH) measurements all fell within 30-50%, which is recommended by the Environmental Protection Agency (EPA) as the range that is most comfortable for indoor air.

Site 07 Existing mechanical systems

Mechanical systems

The mechanical systems vary across the facility, and on-site observations confirmed the following:

• Facility has split systems for heating and cooling in some resident spaces[1] while others have PTAC units[2]. Hallways have split systems, electric convectors, and some PTAC at the end of the hallways[3]. [4]

• The hallways also make use of heat exchangers.

• Kitchen exhaust runs as needed. When operated it

tends to create negative pressure in the space and doesn’t allow the door to close.

• Operable windows are available in most resident rooms[5]. The window construction includes a single pane interior and a single glazed exterior with a 6-inch gap between them, which tends to be fairly leaky.

• Resident room areas vary between 250ft2 and 321ft2 with an 8ft ceiling height.

Site 07

Indoor

air

Air sampling

The first air sampler was deployed at 7:26AM and the last air sampler was collected at 10:05AM, which yielded a total of 10 samples from this site. The table below shows the reported status of this site, COVID negative at the time of the visit, along with the COVID status from the air sample test results: 0 positive, 5 negative, and 5 inconclusive.

Site 07

Site Status: COVIDCOVID present in air samples

Positive Negative Inconclusive 0/10 5/10 5/10

Ventilation & air filtration

This site did not have data points for common areas and resident rooms that have ventilation or HEPA filtration.

The average CO2 measurements remained relatively steady at 610ppm in both the common areas and resident rooms.

The overall relative humidity did not show significant changes, varying slightly between 46% and 49%.

The following page includes CO2 and relative humidity for each sample collected at this site. They are categorized relative to the SARS-CoV-2, ventilation, and HEPA filtration status.

Ventilation Toolkit feedback

Question Response

Q1 Yes

Q2b No

Q2b No, but learned more about the facility.

Q3a Funding is always a concern.

Q3b NA

Q4 5

Q5a It was generally good.

Q5b NA

Q6 No

Q7 NA

Sheet1

No Window Ventilation or HEPA

Inconclusive SARS−CoV−2 Result

for SARS−CoV−2

Site 07 carbon dioxide (CO2) measurements all fell under 1000 parts per million (ppm), within the limits for levels for acceptable indoor air from The American Society of Heating, Refrigeration and Air Conditioning Engineers (ASHRAE).

Sample Number

No Window Ventilation or HEPA

Inconclusive SARS−CoV−2 Result Negative for SARS−CoV−2

Site 0y relative humidity (RH) measurements all fell within 30-50%, which is recommended by the Environmental Protection Agency (EPA) as the range that is most comfortable for indoor air.

Site 08

Mechanical systems

The mechanical systems vary across the facility, and on-site observations confirmed the following:

• Facility is serviced mainly by forced air roof-top unit, with natural gas heating and electric cooling[1][2]. PTAC units are also available in resident rooms[3] [4] along with some split systems.

• The MERV rating of the air filters was unknown since the facility uses an HVAC contractor that takes care of maintenance. There were no replacement filters on-site for our team to inspect and our team did not access the roof at the time of the visit.

• Kitchen exhaust is operated 24/7.

• Operable windows are available in most resident rooms. [5]

• Resident bathroom exhaust is controlled via manual switch that also controls the electric lights.

• The portable HEPA air filters (delivered by OHA) were unpacked and ready for deployment while our team was on-site.

• Resident room areas vary between 271ft2 and 321ft2 with a ceiling height that varies between 8ft and 8.75ft.

Site 08

Indoor air

Air sampling

The first air sampler was deployed at 7:25AM and the last air sampler was collected at 10:36PM, which yielded a total of 10 samples from this site. The table below shows the reported status of this site, COVID negative at the time of the visit, along with the COVID status from the air sample test results: 0 positive, 7 negative, and 1 inconclusive. (2 samples failed lab QC)

Site 08

Site Status: COVIDCOVID present in air samples

Positive Negative Inconclusive 0/8 7/8 1/8

Note: two samples failed quality control and have been excluded

Ventilation & air filtration

This site did not have data points for resident rooms that have ventilation or HEPA filtration.

The average CO2 measurements vary slightly between 610ppm and 640ppm in common areas with and without ventilation or HEPA filtration, respectively, while the resident rooms without ventilation or HEPA filtration measured 690ppm.

The overall relative humidity did not show significant changes, varying slightly between 44% and 45%.

The following page includes CO2 and relative humidity for each sample collected at this site. They are categorized relative to the SARS-CoV-2, ventilation, and HEPA filtration status.

Ventilation Toolkit feedback

Question Response

Q1 Yes

Q2b Not all the information.

Q2b Looking at the filters.

Q3a Staff conflicts since the OHA HEPA filters are noisy, they keep getting turned off or having the flow rate setting lowered.

Q3b NA

Q4 8

Q5a NA

Q5b No, it was not unclear of difficult.

Q6 Remembering questions. (?)

Q7 NA

Sheet1

Site 08 carbon dioxide (CO2) measurements all fell under 1000 parts per million (ppm), within the limits for levels for acceptable indoor air from The American Society of Heating, Refrigeration and Air Conditioning Engineers (ASHRAE).

Site 08 relative humidity (RH) measurements all fell within 30-50%, which is recommended by the Environmental Protection Agency (EPA) as the range that is most comfortable for indoor air.

Site 09

Existing mechanical systems

Mechanical systems

The mechanical systems vary across the facility, and on-site observations confirmed the following:

• Facility is serviced mainly by forced air roof-top unit, with natural gas heating and electric cooling. PTAC units are also available in resident rooms and some other exterior perimeter spaces like the therapy gym. [1][2]

• The MERV rating of the air filters was unknown since the facility uses an HVAC contractor that takes care of maintenance. However, there were some loose filters in the attic that varied from MERV 8 to 12. [3][4]

• Operable windows are available in most resident rooms.

• No air flow was detected from the resident bathroom exhaust, regardless of switch setting.

• The portable HEPA air filters (delivered by OHA) were unpacked and ready for deployment while our team was on-site.

• Resident room areas vary between 236ft2 and 327ft2 with an 8ft ceiling height.

Site 09

Indoor air

Air sampling

The first air sampler was deployed at 7:38AM and the last air sampler was collected at 11:11AM, which yielded a total of 10 samples from this site. The table below shows the reported status of this site, COVID negative at the time of the visit, along with the COVID status from the air sample test results: 2 positive, 4 negative, and 2 inconclusive. (2 samples failed lab QC)

Site 09

Site Status: COVIDCOVID present in air samples

Positive Negative Inconclusive 2/8 4/8 2/8

Note: two samples failed quality control and have been excluded

Ventilation & air filtration

This site did not have data points for resident rooms that have ventilation or HEPA filtration.

The average CO2 measurements vary between 680ppm and 750ppm in common areas with and without ventilation or HEPA filtration, respectively, while the resident rooms without ventilation or HEPA filtration measured 860ppm.

The overall relative humidity did not show significant changes, varying slightly between 40% and 41% in the common areas, while resident rooms measured at 42%.

The following page includes CO2 and relative humidity for each sample collected at this site. They are categorized relative to the SARS-CoV-2, ventilation, and HEPA filtration status.

Ventilation Toolkit feedback

Question Response

Q1 Yes

Q2b Yes, setting up the 3 pallets of HEPA filters that OHA sent.

Q2b Currently fixing some of the HVAC system.

Q3a There was not a plan of what to do with the filters until our visit that explained a little about the HEPA units.

Q3b NA

Q4 9.5

Q5a It was clear and easy.

Q5b NA

Q6 No

Q7 Emailed an electronic copy of items (Brochure, manual, 1 page suggestion and calculation) I gave out physically during the visit.

Sheet1

Site 09 carbon dioxide (CO2) measurements all fell under 1000 parts per million (ppm), within the limits for levels for acceptable indoor air from The American Society of Heating, Refrigeration and Air Conditioning Engineers (ASHRAE).

Site 09 relative humidity (RH) measurements all fell within 30-50%, which is recommended by the Environmental Protection Agency (EPA) as the range that is most comfortable for indoor air.

Site 10

Mechanical systems

The mechanical systems vary across the facility, and on-site observations confirmed the following:

• Facility leases space from an adjacent hospital. The heating system is mainly a hot water boiler with water pipes in the ceiling. It is controlled separately by the adjacent hospital. [1]

• Some resident rooms and common spaces have PTAC. [2]

• There were some interior spaces that had ceiling vents of unknown control.

• Due to the control the facility by the hospital staff and timing I was not able to get as detailed an interview of the operation. There wasn’t transparent evidence of active air ventilation in most resident rooms and the status of the filters or efficiency in those spaces is unclear.

• The portable HEPA air filters (delivered by OHA) were on-site before our visit and a number of the units were already set up around the facility. Our team reviewed their settings and operation[3][4]. The placement of the units was closer to perimeter walls than recommended, but this is a result of prioritizing safety and making sure circulation corridors are clear.

• There was the deployment of a few of the new HEPA filters that they just got and we reviewed the settings[4]. There were a few other air units in two resident rooms, but it was unclear if they were operated regularly. [3][5][6]

• Operable windows are available in most resident rooms and were generally open to some level. [1]

• Restrooms were in resident rooms were on regardless of light switch.

• Resident room areas vary between 167ft2 and 225ft2 with a 9.5ft ceiling height.

Site 10

Indoor air

Air sampling

The first air sampler was deployed at 10:35AM and the last air sampler was collected at 1:35PM, which yielded a total of 10 samples from this site. The table below shows the reported status of this site, COVID negative at the time of the visit, along with the COVID status from the air sample test results: 0 positive, 10 negative, and 0 inconclusive.

Site 10

Site Status: COVIDCOVID present in air samples

Positive Negative Inconclusive 0/10 10/10 0/10

Ventilation & air filtration

The average CO2 measurements vary between 730ppm and 825ppm in common areas with and without ventilation or HEPA filtration, respectively, while the resident rooms vary between 770ppm and 800ppm with and without ventilation or HEPA filtration, respectively.

The overall relative humidity did not show significant changes, varying slightly between 41% and 42% in the common areas, while resident rooms hovered at 41%.

The following page includes CO2 and relative humidity for each sample collected at this site. They are categorized relative to the SARS-CoV-2, ventilation, and HEPA filtration status.

Ventilation Toolkit feedback

Our team was unable to conduct a follow-up interview for this site.

Site 10 carbon dioxide (CO2) measurements all fell under 1000 parts per million (ppm), within the limits for levels for acceptable indoor air from The American Society of Heating, Refrigeration and Air Conditioning Engineers (ASHRAE).

Site 10 relative humidity (RH) measurements all fell within 30-50%, which is recommended by the Environmental Protection Agency (EPA) as the range that is most comfortable for indoor air.

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04 DISCUSSION & CONCLUSIONS

Air sampling and ventilation

Results and Conclusions

Summary of all spaces sampled

QPCR SARS-CoV-2 results of air sampling

Ventilation status

On-site measurements of CO2 and relative humidity across all ten sites and during the sampling period, looking at the differences between the resident rooms and the common spaces and whether or not there was any ventilation and/or HEPA filtration.

Environmental monitoring indicated that the presence of natural ventilation and/or HEPA filtration was associated with a slightly, but not significantly, lower CO2 level. In all spaces sampled, the average CO2 was below 1000 ppm regardless of other variables.

Relative humidity (RH) was not significantly correlated with the presence of natural ventilation and/or HEPA filtration. However, due to the relatively low number of samples from spaces with these features, (n = 23), the presence of sampling bias may is a strong possibility.

The portable HEPA filters provided by OHA were observed in facilities at sites 06 through 10. However in most cases they were either not deployed, or only recently deployed, before our team arrived on site. Additionally, facilities reported that there were conflicts with staff that considered the HEPA units noisy and as such either turned them off or set them to the lowest filtration setting.

SARS-COV-2 Data

In this study, CO2 and RH levels were not significantly associated with SARS-COV-2 presence.

However, qPCR results from sites with confirmed COVID cases indicated that, largely, viral particles were present outside of the rooms of infected residents.

Summaries of the average values for CO2 and RH are shown on the following pages.

Ventilation Toolkit Facilities feedback

Seven out of the ten sites provided us with feedback. The participating facilities included sites 03-09. Facilities from sites 01, 02, and 10 were unavailable or unreachable. The overall sentiment was overwhelmingly positive, as shown by the above chart where 1 corresponds to "not useful at all" and 10 corresponds to " extremely useful". The average usefulness rating came out to 7.4 out of 10, with a maximum of 9.5 and minimum of 5

The majority of responses indicated that the toolkit was clear and easy to use, however one interviewee mentioned that it seemed to be aimed at owners/ operators with less HVAC/technical experience. The recommended revisions from this particular interviewee was a request to include even more suggestions/guidance into the toolkit, but did not indicate any specifics.

In instances where the toolkit was applied and changes were made in facilities, several uses were mentioned:

• Air filter changes, upgrades to higher MERV rating, and planning for regular maintenance.

• Adjusting fan operating schedules to run 24/7 in hallways so as to utilize air filters regardless of whether the system is in heating or cooling mode.

• More frequent use of bathroom exhaust fans.

In general, the toolkit was primarily used to improve air filtration and to adjust ventilation frequency in key areas (common areas and circulation pathways). Additionally, in cases where owners/managers were unable to implement any tangible changes, the sentiment was that they still found the toolkit informative about the indoor air quality and ventilation in their facilities.

The interview responses are available in Section 05 Supplemental Materials along with the Ventilation Toolkit, which is also available for download on the IHBE website: https://buildhealth.uoregon.edu/ventilation-toolkit

05 SUPPLEMENTAL MATERIALS

Environmental data and qPCR Results

Line summary, Sites 01-05

Environmental data and qPCR Results

Line summary, Sites 06-10