Cluster of Respiratory Illness in British Columbia Linked to Poor Air Quality at an Indoor Ice Arena: a Case Report
Clinical
Hilary Drake, BSc, Courtney Zimmerman, BTech, CPHI(C), Guy Osachoff, CPHI(C), Greg Baytalan, BSc, CPHI(C), Muddassir Siddiqui, BDS, MPH, Gillian Frosst, BSc, MPH, Silvina C. Mema, MD, MSc, FRCPC Cluster of respiratory illness in British Columbia linked to poor air quality at an indoor ice arena: A case report
An example of the importance of health care providers reporting disease clusters to public health authorities.
ABSTRACT: In February 2019, a 56-year-old male matter had accumulated in the indoor ice arena. [Table] and performed a descriptive analysis was admitted to Kelowna General Hospital with a Numerous contributing factors were identified, of data collected from interviews and medical respiratory illness following recreational hockey including the use of older-model ice resurfacing records. In addition, the team conducted envi- practice at an indoor ice arena. During his hospi- and edging equipment, the unseasonably cold ronmental inspections of the arena. talization, he disclosed that several of his hockey outdoor weather conditions at the time, and the The Interior Health team learned that af- teammates had similar respiratory symptoms. This failure of heating, ventilation, and air conditioning ter 16 players attended a hockey practice on 8 prompted the hospitalist physician to contact an equipment. This case report highlights the impor- February, 12 reported becoming ill (attack rate: Interior Health medical health officer regarding a tance of health care providers reporting disease 75%). The team interviewed 11 of the 12 play- potential cluster of respiratory illness. The inves- clusters to public health authorities, even when ers; 1 player was out of the country and could tigation that was launched found toxic levels of the causative agent may not be reportable under not be reached. Of the 11 players interviewed, carbon monoxide, nitrogen dioxide, and particulate the British Columbia Public Health Act. all were nonsmokers and none reported any recreational drug use. The age range of those Case data affected was 35 to 58 years (mean 52 years). Ms Drake is a medical student at On 12 February 2019, a hospitalist physician at The most commonly reported symptoms the University of British Columbia. Ms the Kelowna General Hospital contacted the were shortness of breath (91%), followed by Zimmerman is director of environmental Interior Health on-call medical health officer cough (64%) and hemoptysis (36%). Of the 11 public health at Interior Health. Mr (MHO) to report a cluster of respiratory ill- individuals interviewed, 5 (45%) sought medical 1 Osachoff is an environmental health ness. A 56-year-old male had been admitted care and 4 (36%) obtained chest X-rays within officer at Interior Health. Mr Baytalan is to hospital with acute respiratory distress on 9 24 to 72 hours from the onset of symptoms. Of a specialist environmental health officer February after playing hockey on 8 February at the individuals who obtained chest X-rays, 3 at Interior Health. Mr Siddiqui is a public an indoor ice arena. While recovering in hos- (75%), including the patient in the index case, health epidemiologist at Interior Health. pital, the patient disclosed that several fellow had a hazy lung lesion of increased density, Ms Frosst is manager of the epidemiology players had developed respiratory illness with which the radiologist reported as a patchy and surveillance unit at Interior Health. similar symptoms on 8 and 9 February. ground-glass nodularity in pulmonary airspace. Dr Mema is a medical health officer at A cluster investigation team was struck im- The patient in the index case was the only Interior Health and a clinical assistant mediately to determine if the players had been player to require hospitalization, with an initial professor in the School of Population and exposed to a disease-causing agent. The team presumptive diagnosis of community-acquired Public Health at the University of British was led by an Interior Health MHO and in- atypical pneumonia. The patient’s blood cell Columbia. cluded three environmental health officers, a count was normal and his chest X-ray showed communicable disease specialist, and an epide- patchy multifocal airspace disease most This article has been peer reviewed. miologist. The team developed case definitions prominently involving the upper lung zones
50 BC Medical Journal vol. 62 no. 2 | march 2020 Drake H, Zimmerman C, Osachoff G, Baytalan G, Siddiqui M, Frosst G, Mema SC Clinical bilaterally. Follow-up chest X-rays showed rapid Table. Case definitions. and significant improvement, and the patient was fully recovered by the time of discharge Confirmed Any person present at the indoor ice arena and surrounding area on 8 February 2019 case experiencing respiratory illness symptoms on or after that date: on 13 February. Nasopharyngeal swabs were • New or worsening cough negative for influenza and respiratory syncytial and virus. Multiplex nucleic acid testing (NAT) • Additional respiratory illness symptoms (may include shortness of breath, hemoptysis, was negative for viruses and bacteria. Sputum dizziness, headache, and/or fever) culture was negative for tuberculosis after a and 6-week incubation. • Abnormal chest X-ray results An inspection of the arena building and ice rink on 12 February found a number of is- Probable Any person present at the indoor ice arena and surrounding area on 8 February 2019 case experiencing respiratory illness symptoms on or after that date: sues. The ice resurfacing machine was in poor • New or worsening cough repair, the HVAC (heating, ventilation, and air and/or conditioning) system was malfunctioning, and • Additional respiratory illness symptoms (may include shortness of breath, hemoptysis, two rooftop fans for the furnace and make-up dizziness, headache, and/or fever) air were not working. Data from real-time air quality monitors were not available. The West Kelowna Fire Department and Fortis BC also inspected the arena on the evening of 12 Feb- ruary and at the time of their inspection were edging machines. Ice resurfacing machines or produces a variety of symptoms, including unable to detect any noxious gases. Howev- resurfacers are primarily fossil-fueled vehicles headache, malaise, nausea/vomiting, and dizzi- er, subsequent air monitoring on 4 March by for maintaining the entire ice surface and are ness.10,11 Signs and symptoms of nitrogen diox- Technical Safety BC (previously BC Safety commonly referred to as Zambonis, regard- ide poisoning are primarily respiratory related, Authority) identified levels of carbon monox- less of brand or manufacturer. Ice resurfacers including cough, hemoptysis, throat irritation, ide (CO) well above the safety threshold, par- are used together with ice edgers, which shave dyspnea, and chest pain.4,6,12,13 ticularly near the ice surface where a four-cycle and level the edge of the ice rink near the sur- Indoor ice rinks are used most commonly gasoline-powered edging machine was operat- rounding boards. Edging usually takes place for hockey, ringette, figure skating, and general ing in idle mode. once daily or every other day and is typically recreation.3 During these exercise-related ac- Arena staff reported that on 8 February sig- followed by ice resurfacing; however, ice resur- tivities, participants increase their respiratory nificant ice maintenance had been conducted facing can take place independently of edging rate and risk inhaling more toxic gases and from 8:15 a.m. to 2:00 p.m., with the ice resur- and is commonly done more frequently—as particulate matter, if present.4 Compared with facing machine operating for about 3.5 hours. often as every hour.2 carbon monoxide uptake at rest, carbon mon- A gasoline-powered ice edging machine was oxide uptake during exercise can increase up also used at this time. Rink operators recalled Air pollutants to 400%.14 Furthermore, individuals exercising that on 8 February the weather was unusually Older models of ice maintenance equipment on an ice rink are near the cold ice surface cold for the Central Okanagan at -21 °C, which operate using an internal combustion engine where less-effective mixing of combustion led to the bay door for the ice resurfacing ma- fueled by either propane or gasoline, which can emissions occurs with the warmer air above.15 chine being closed during maintenance on this produce high levels of air pollutants, includ- This puts athletes or recreational users at the 3,4,6,9 particular day. None of the staff members who ing carbon monoxide, nitrogen dioxide (NO2), highest risk for toxic exposure. Those worked that day had respiratory symptoms. Of and ultrafine/fine particulate matter.3-5 Studies especially at risk for developing complica- interest, the first player to arrive at the arena comparing outside air with air inside arenas tions from inhaling CO, NO2, and particulate on 8 February noted that he saw a yellow haze that use ice resurfacing machines powered by matter are children, pregnant women, and on the surface of the ice and around the ceiling fossil fuels have found a 60-fold to 300-fold individuals with pre-existing cardiovascular lights. None of the other players interviewed increase in CO, a 10-fold increase in NO2, and or respiratory conditions such as congestive reported seeing this haze. a 20-fold increase in small particulate matter.6-8 heart failure or asthma.8,9 These contaminants can result in significant Discussion health risks.5 Factors influencing pollutant levels
Poor indoor air quality at indoor ice arenas is High concentrations of CO and NO2 have The construction of the indoor ice arena can 2-9 known to be a source of health complaints. been found in individuals who spend time influence pollutant levels. Arenas with poor Ice rinks at indoor facilities are typically in indoor ice arenas, including workers and ventilation, including inadequate natural venti- cleaned and smoothed by ice resurfacing and hockey players.4,8,9 Carbon monoxide poisoning lation or inadequate mechanical ventilation, as
BC Medical Journal vol. 62 no. 2 | march 2020 51 Clinical Cluster of respiratory illness in British Columbia linked to poor air quality at an indoor ice arena well as arenas with mechanical failure of exist- As well, the machines should be stored in a a chemical exposure as the most plausible cause, ing ventilation systems, have increased levels of well-ventilated part of the arena with direct allowing the MHO to make recommendations 16 ambient CO and NO2. Furthermore, the size access to the outdoors or an exhaust hose to to mitigate the ongoing risk at the arena. of an arena can influence pollutant levels, with extract and redirect the fumes outside. While suspected food or waterborne ill- smaller arenas having higher NO2 levels than nesses or clusters of gastrointestinal illness are larger arenas.17 Ice surfaces used for hockey have Monitoring reportable in BC, there is no requirement to re- boards taller than many young skaters, thereby The incident described in this case report high- port illnesses with causes other than those listed trapping the heavier-than-air NO2 within this lights the importance of real-time air quality in the regulation as “prescribed” infectious or cooler dense air environment above the ice sur- monitoring in indoor ice arenas and the need hazardous agents. Therefore, a health care pro- face at the inhalation height of many youths. to follow administrative vider could be dealing with Far worse consequences could have resulted if protocols such as proper a significant illness cluster, children rather than adult males had entered ventilation maintenance. Far worse consequences such as the one we investi- the ice surface immediately after this prolonged While monitoring com- could have resulted gated, yet not be required ice maintenance activity. pliance with safety stan- if children rather to report to the MHO. In In this particular cluster of respiratory ill- dards at indoor ice arenas contrast, the Alberta Pub- than adult males had ness, a number of factors likely contributed to is the shared responsi lic Health Act (Section 26 poor air quality. Doors closed because of un- bility of employers, local entered the ice surface Notification of epidemics seasonably cold weather conditions, prolonged governments, and Work- immediately after and other threats) requires 18 ice maintenance, and HVAC equipment failure SafeBC, a national or this prolonged ice that any disease occurring created the perfect storm opportunity for toxic provincial guideline on maintenance activity. in epidemic form or at an levels of CO, NO2, and particulate matter to acceptable levels of CO unusually high rate, or any accumulate indoors. The higher respiratory rate and NO2, including pro- illness suspected to pose a of players during exercise increased their expo- tocols to mitigate toxic public health threat, be re- sure to pollutants over that of staff who did not gas levels, could help maintain public safety. ported to an MHO.21 Furthermore, in Alberta, report symptoms.14 Of note, during the winter of 2020–21, Health reporting requirements extend beyond health Carbon monoxide and nitrogen dioxide Canada will be testing the efficacy of two in- care workers to teachers and persons in charge emissions result when fossil-fuel-powered terventions on air quality at indoor ice arenas, of an institution. engines are used.3-5 Ways to prevent or mini- one in Ontario and one in Saskatchewan.19 This indoor ice arena incident highlights the mize emissions include decreasing the time a The impact of fuel type on CO and NO2 con- benefit of front-line health care professionals fossil-fuel-powered ice resurfacing machine is centrations will be assessed and the efficacy of collaborating with public health officials, and 4 in operation indoors, ensuring adequate ven- various ventilation strategies on CO and NO2 the importance of encouraging health care pro- tilation to prevent buildup of toxic gas, and concentrations will be quantified. The impact viders to report unusual events with possible transitioning to electric ice resurfacing ma- of other factors on indoor air quality will also public health implications. Efforts are under- chines, although this last strategy can be cost be studied, such as arena volume, number of ice way to amend BC’s regulation using language prohibitive. Other solutions include manually resurfacings, temperature, and relative humidity. similar to Alberta’s to require more inclusive running the ventilation system longer, opening reporting. doors during resurfacing, and ensuring that Reporting the ventilation system is working properly. In- The case study described here illustrates the Summary terestingly, shortly after the incident, the two importance of promptly reporting clusters of Several factors, including doors being closed (and only) ceiling exhaust fans were repaired respiratory illness to an MHO. The BC Public due to cold weather, prolonged ice maintenance, and deemed to be functioning properly. How- Health Act (Section 10, Mandatory reporting of and HVAC equipment failure, led to a build- ever, many months later it was discovered that infection or exposure) requires that health care up of toxic gases in an indoor ice arena. This the air ducts had been intentionally blocked, providers notify an MHO if they have reason caused 12 previously healthy adults to report most likely for energy conservation purposes. to believe a patient is infected with a reportable respiratory symptoms. The treating physician Therefore, the fans were not performing their communicable disease.20 This includes suspected contacted an Interior Health MHO about a designed task until the blockages were removed. food or waterborne illnesses as well as clusters possible respiratory illness cluster, which led to Studies show that CO levels are highest dur- of gastrointestinal illness, as detailed in the Re- a prompt investigation, despite this reporting ing the use of an ice resurfacer and immediately porting Information Affecting Public Health not being mandated by the current BC Public afterwards,5 suggesting that arenas should use Regulation. While a communicable disease was Health Act. The success of the investigation the ventilation system throughout the proce- initially suspected in the index case, a prompt highlights the importance of including illness dure and after resurfacing has been completed. and thorough cluster investigation pinpointed clusters in the reporting guidelines for health
52 BC Medical Journal vol. 62 no. 2 | march 2020 Drake H, Zimmerman C, Osachoff G, Baytalan G, Siddiqui M, Frosst G, Mema SC Clinical
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