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Insights into UVGI implementation in resource-constrained settings?

By Robert Flick | 09 Mar, 2016

Dear All,

First, let me thank all of the contributors to community, and especially the moderators, for the extremely helpful dialogue. I don't post often, but read frequently, and the conversations have inspired much of my thinking around TB-IPC, especially with regards to UVGI.

I work in a research setting in Malawi, and we'd like to explore the feasibility of installing UVGI in some of our clinic spaces. I've reviewed much of the literature published by Professor Nardell and colleagues, which has been instrumental in our even considering this as an option. I remain concerned however, that implementing and maintaining this technology in our setting may be very challenging. I'm curious if anyone here has implemented a UVGI system in a similarly resource-constrained setting and has any lessons to share. My specific concerns are as follows:

1. Ensuring regular supply of fixtures and bulbs. I have not had success finding any locally. The literature I've reviewed imported them from the US; while this is possible, it is expensive and not ideal.

2. Maintaining fixtures under irregular and hazardous power conditions. Frequent blackouts and power surges render the life of most electronics here. Any fixture would have to be durable to unexpected surges, and be able to run off generator power when grid power is switched off. Also, ensuring safe and adequate fluence rates given daily variance in power supply.

3. Servicing fixtures. I'm not sure that technical training for the regular cleaning and irradiance checks is readily available in our setting. While it doesn't sound overly complicated, I want to be careful as mistakes could obviously lead to harm of both technician and others using the room.

Contrary to how this list may make it sound, I do remain optimistic that we can get something working. I would appreciate any feedback from community members who have gone through this process, rather than trying to re-invent the wheel if someone has been down this path before.

Kind regards,

Robbie Flick

Replies

 

Grigory Volchenkov, MD Moderator Replied at 5:09 AM, 9 Mar 2016

Dear Robert,
1. I would recommend to choose fixture model carefully from known brands with proven effectiveness and safety. Actually few manufacturers produce high quality germicidal UV lamps, they are more costly, but cheap lamps usually have low 254 nm output, last MUCH shorter and produce lots of ozone.  I would not compromise. I would choose fixtures with tubular lamps - less expensive, higher lifetime, easier available.Can not recommend particular brands because of blog policy but they all are well known.
2. I have no personal experience with irregular and hazardous power conditions.
3. Very important is competent installation and commisioning. UV-C radiometer with 254 nm probe should be used for it. It is also required for periodic monitoring of their safety and effectiveness, which is not complicated, but technician needs to understand theory and some training. One technician (with one radiometer) can cover maintenance of hundreds or thousands of fixtures - one for region(s) or even country.   Kind regards,
Grigory Dr. Grigory V. Volchenkov 

Chief Doctor
Vladimir Regional TB Control Center

Sudogodskoe shosse, 63
Vladimir 600023 RUSSIA

phone/fax work: +7(4922)323265
mobile +7 9206253227; +7 9190189226

Edward Nardell, MD Moderator Replied at 1:31 PM, 9 Mar 2016

Dear Robbie,

Thanks for your kind words. As a reader here you know that sustainability
under high burden, resource limited conditions is our current focus for
UVGI, or GUV for Germicidal Ultraviolet air disinfection. The world
"irradiation" gets confused with ionizing radiation and causes unnecessary
fear, so we are trying to get rid of the I in UVGI.

My comments complement those of Grigory. Grigory has the distinction of
installing and maintaining a large system of GUV in Vladimir, Russia, but
Russia is now Malawi and we recognize issues like power supply that you
will have to deal with in your setting. Please see my comments between your
points, below.

Ed

On Wed, Mar 9, 2016 at 4:11 AM, Robert Flick via GHDonline <
> wrote:

> Robert Flick
> <http://email.ghdonline.org/c/eJxlUMtuhDAM_BpyK8qLhBxyqFTtb6AsOBA1JCh4hfbva_Za...>
> started a discussion
> <http://email.ghdonline.org/c/eJxlUMuOwyAM_JpwS8QjKcmBQ6VVf6OiQBJLPCJwturfr9Pr...>
> in TB Infection Control
> <http://email.ghdonline.org/c/eJxlT82KhDAMfhp7lKTtWD30sLDMa0iZRi3UVmoGmbffONeF...>:
>
>
> Dear All,
>
> First, let me thank all of the contributors to community, and especially
> the moderators, for the extremely helpful dialogue. I don't post often, but
> read frequently, and the conversations have inspired much of my thinking
> around TB-IPC, especially with regards to UVGI.
>
> I work in a research setting in Malawi, and we'd like to explore the
> feasibility of installing UVGI in some of our clinic spaces. I've reviewed
> much of the literature published by Professor Nardell and colleagues, which
> has been instrumental in our even considering this as an option. I remain
> concerned however, that implementing and maintaining this technology in our
> setting may be very challenging. I'm curious if anyone here has implemented
> a UVGI system in a similarly resource-constrained setting and has any
> lessons to share. My specific concerns are as follows:
>
> 1. Ensuring regular supply of fixtures and bulbs. I have not had success
> finding any locally. The literature I've reviewed imported them from the
> US; while this is possible, it is expensive and not ideal.
>
EN: I am happy to make specific fixture recommendations based on our
experience by email directly (). There is a good
manufacturer in the Netherlands and at least two manufacturers in South
Africa in addition to two high quality manufacturer's in the US, one of
whom has fixtures that can be assembled in country, but not by the user.
A key requirement is knowing the exact UV output in Watts. As far as I
know, only 2 high quality US manufacturers and 1 inferior US fixture have
had total UV output measured. One South African fixture was measured and
output was low, so we cannot recommend it. The other South African
manufacturer has not had total fixture output measured as far as I know.
The two fixture models that we used in the South African study varied from
total fixture output of 0.25 W (generated by 110 W input, compact folded
lamps, and poor reflectors and louvers) to 0.49 W (generated by only 26 W
input, linear lamps, and excellent reflector and louvers) - with a 10 x
difference in efficiency. Not only is power usage less with the more
efficient fixtures, but one fixture covers twice the volume and there are
fewer fixtures to maintain. Please do not purchase a fixture unless its
total output has been measured by a qualified independent laboratory. If in
doubt, ask here. If you want to consider South African fixtures I can give
you contact information and perhaps you can ask them to have the output
measured as a condition of sale. If you purchase several fixtures, the two
quality US manufacturers with measured fixtures will likely be able to
provide a substantial discount - or so I have been told.

2. Maintaining fixtures under irregular and hazardous power conditions.
> Frequent blackouts and power surges render the life of most electronics
> here. Any fixture would have to be durable to unexpected surges, and be
> able to run off generator power when grid power is switched off. Also,
> ensuring safe and adequate fluence rates given daily variance in power
> supply.
>
EN: When we finally have LED UV fixtures (we are about to test prototypes,
but they are still too expensive), the power supply issue will be less
critical as they can run off of battery back up or solar power. In the
meantime, electronic ballast are less likely to succumb to outages than
older ballast types. South Africa also has frequent power outages and we
use a generator, and the fixtures at the AIR facility have survived. Re.
maintenance, we would like this ultimately to be done NOT BY THE HOSPITAL,
but by a company trained and certified that would provide regular
maintenance for a fee. Obviously, this does not yet exist in Malawi.
Grigory does his own in Vladamir with a good UV meter and a protocol. That
information can be shared. It is not rocket science and can be done - you
just cannot be sure that hospital maintenance will do it properly without
training and close supervision.

> 3. Servicing fixtures. I'm not sure that technical training for the
> regular cleaning and irradiance checks is readily available in our setting.
> While it doesn't sound overly complicated, I want to be careful as mistakes
> could obviously lead to harm of both technician and others using the room.
>
EN: maintenance mentioned above, but safety is the other concern. One a
system is commissioned - shown to put out UV that is both enough to be
effective in the upper room and safe in the lower room, it should not
change. Those maintain it require training not only how to do the
maintenance - but how to avoid eye injury - largely being sure lamps are
off before cleaning and that safety glasses are used when taking
measurements by hand in the upper room.

> Contrary to how this list may make it sound, I do remain optimistic that
> we can get something working. I would appreciate any feedback from
> community members who have gone through this process, rather than trying to
> re-invent the wheel if someone has been down this path before.
>
EN: you definitely can make it work. However, I am also familiar with
mistakes. In our own PIH-supported hospital in Butaro, Rwanda, a visit a
year or two after upper room UVGI installation found high reflection off of
a slanted ceiling that had not been anticipated and there had been no
commissioning before use. Fixtures were full of dead bugs and some were
pulling off the walls - poor anchors. But is is no more difficult to do it
right than do it poorly - just requires knowledge and knowledge is more or
less free on sites like this. We can help you do it right.

Best wishes,

Ed Nardell, MD

> Kind regards,
>
> Robbie Flick
>
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Robert Flick Replied at 2:18 AM, 11 Mar 2016

Dear Grigory, Ed,

Thank you so much for the helpful and encouraging responses. We've made some headway in identifying local companies who can handle installation, commissioning, and maintenance—very good news. Thanks for the correction on GUV, that makes sense. Look forward to reading more about LED fixtures when the time comes.

Grigory—are you able to share your maintenance protocol that Ed referenced? My email is . It would be helpful to ensure that the operating procedures of our local supplier match what is recommended by experts. If not, and we have to draft our own, I would be grateful for the guidance.

Ed—Thank you. I've reached out via email for the specific recommendations.

To the rest of the community, if anyone else has any insights from their own experience making this technology work under challenging circumstances, I would be very grateful.

All the best,

Robbie

Grigory Volchenkov, MD Moderator Replied at 3:33 PM, 13 Mar 2016

Dear Robert,

The upper room UVGI maintenance protocol we developed and use is in Russian. It includes the following:
• Fixture cleaning:
o Responsible staff (nurses)
o Frequency (monthly)
o 70% alcohol distribution (2 ml per one TUV-30 lamp)
• Monitoring
o Effectiveness (measuring irradiance @ 1m from source in upper space)
o Safety (peak irradiance in occupied space @ eye level)
o Adjustments if needed (our fixtures are adjustable)
o Record keeping
• Lamps replacement (we replace when for clean lamp irradiance drops below 100 uW/cm2 @ 1 m)
• Lamps procurement
• Education
o Technician
o HCWs
o patients
• Safety measures
o Switching off for cleaning & maintenance
o Glasses use for measurement & adjustments
• TB transmission risk assessment (semiannually) to identify new sites for lamps installation or relocation.

suheyla surucuoglu Replied at 3:56 PM, 13 Mar 2016

Dear Grigory,
Thank you very much for the UVGI maintenance list. It would be really helpful for our lab's practices.

Prof. Dr. Suheyla Surucuoglu
Celal Bayar University Medical Faculty
Tuberculosis Laboratory
Manisa, Turkey

Robert Flick Replied at 2:36 AM, 14 Mar 2016

Grigory, thank you so much for the comprehensive list. With regards to measuring irradiance to ensure adequate levels in the upper space, do you simply use a standard UV meter 1m from the source? And for ensuring safe levels at eye level, how many different points in the room do you measure at eye-level before you are satisfied that there are safe levels throughout?

Best,

Robbie

Grigory Volchenkov, MD Moderator Replied at 5:11 AM, 14 Mar 2016

Robert,
UV-C meter with 254 nm detector (probe) should be used for measurements. It should be accuarate enough at levels of 0.1 uWcm2 to assess safety in occupied space. We use GigaHertz Optik X9 11-u meter with UV-3718-4 detector.
For faster and actually more accurate measurements we use PEAK mode to catch maximal irradiance level at eye level for people standing, sitting, laying in the room according to its occupancy purpose. Detector should be directed in various directions - not only to the fixture, but to possible reflective surfaces or objects. In practice it takes seconds.
All best,
Grigory  Dr. Grigory V. Volchenkov 

Chief Doctor
Vladimir Regional TB Control Center

Sudogodskoe shosse, 63
Vladimir 600023 RUSSIA

phone/fax work: +7(4922)323265
mobile +7 9206253227; +7 9190189226

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