Statistical Considerations for Bioaerosol Health-Risk Exposure Analysis
Air and surface sampling was conducted to confirm the types of microbiological contamination within a hospital facility in the southern United States, identify indicators of indoor microbiological contamination, and profile the aero-biological makeup of the inside air (ISA) for comparisons to outside air (OSA) and reference concentrations, where applicable. The investigation strategy recommended by the American Conference of Governmental Industrial Hygienists (ACGIH) was utilized to assess indoor environmental quality and conditions found within the hospital facility. The ACGIH methodology is guided by the text Bioaerosols: Assessment and Control. (Macher 1999) Biological contamination within a hospital environment is of great concern as bacteria and fungi are important causes of nosocomial infection (NI). It is estimated that the overall hospital-acquired infection rate in Europe and North America is between 5 and 10%. (Kalliokoski 2003) A substantial number of bacteria and fungi are capable of spreading via the airborne route in hospitals, and airborne transmission accounts for approximately 10% of all NI. (Eickhoff 1994; Kalliokoski 2003) Contaminated Heating, Ventilating, and Air Conditioning (HVAC) systems and infiltration of unfiltered outside air have been implicated in airborne outbreaks of NI via infective aerosols, dust, and contaminated filters. (Lentino, Rosenkranz et al. 1982; Rhame 1991; Eickhoff 1994) Certain underlying diseases, procedures, hospital services, and categories of age, sex, race, and urgency of admission have been shown to be significant risk factors for nosocomial infection. (Freeman and McGowan 1978) The day-specific incidence of nosocomial infection rises from near zero on the first hospital day to maximal during the fourth through seventh weeks of hospital stay. (Freeman and McGowan 1981) Nosocomial infections can affect patients in any location within a hospital. (Boss and Day 2003) The Centers for Disease Control (CDC) estimates that 2 million patients develop hospital-acquired infections annually and as many as 88,000 die as a result. (CDC 1992) Hospitals typically maintain a patient population with increased susceptibility to infection and factors nherent to the healthcare environment contribute to the risk associated with acquiring an infection during a hospital admission. (Dulworth and Pyenson 2004) Environmental control and high efficiency filtration are critical to preventing person-to-person and environmentally related infections in hospitals. (Wenzel 1997; Boss and Day 2003) Current evidence indicates that excessive moisture indoors promotes microbial growth and is associated with an increased prevalence of symptoms due to irritation, allergy, and infection. It is widely accepted in various scientific communities that indoor microbiological contamination presents unacceptable conditions for the preservation of human health, and that removal and prevention of microbial contamination is necessary and prudent. (Pope, Patterson et al. 1993; Macher 1999; Agency 2001; ACOEM 2002; Fung and Hughson 2002; Redd 2002; CDC 2003; Fung and Hughson 2003) The inherent variability of microbiological organisms in air presents a challenge for conducting air sampling that provides meaningful results for the evaluation of human exposure and health risk. In general, bioaerosol air sampling is highly variable and prone to error. Multiple and replicate samples over subsequent days are necessary to characterize exposure and multiple samples per sample location are required to evaluate human exposure in that particular location. An air and surface sampling plan was designed to address the inherent variability and error associated with air sampling and to evaluate the exposure and subsequent health risk to patients, visitors, and staff in a hospital facility. The objectives of this chapter are to highlight the necessity for multiple (replicate) air samples per sample location to conduct valid assessments of the airborne concentrations of bioaerosols.