UNDERSTANDING THE EFFECTIVENESS OF AIR DISINFECTION TECHNOLOGIES AND FACTORS THAT FACILITATE AND INHIBIT THE IMPLEMENTATION OF THESE TECHNOLOGIES IN HEALTH CARE SETTINGS IN SUB-SAHARAN AFRICA (SSA)
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Citation Sheriff, Habib Khalifa Nabiyou. 2021. UNDERSTANDING THE EFFECTIVENESS OF AIR DISINFECTION TECHNOLOGIES AND FACTORS THAT FACILITATE AND INHIBIT THE IMPLEMENTATION OF THESE TECHNOLOGIES IN HEALTH CARE SETTINGS IN SUB- SAHARAN AFRICA (SSA). Master's thesis, Harvard Medical School.
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UNDERSTANDING THE EFFECTIVENESS OF AIR DISINFECTION TECHNOLOGIES
AND FACTORS THAT FACILITATE AND INHIBIT THE IMPLEMENTATION OF THESE
TECHNOLOGIES IN HEALTH CARE SETTINGS IN SUB-SAHARAN AFRICA (SSA)
HABIB SHERIFF
A Thesis Submitted to the Faculty of
The Harvard Medical School
in Partial Fulfillment of the Requirements
for the Degree of Master of Medical Sciences in Global Health Delivery
in the Department of Global Health and Social Medicine
Harvard University
Boston, Massachusetts.
April, 2021
Thesis Advisor: Dr. Edward Nardell Habib Sheriff
UNDERSTANDING THE EFFECTIVENESS OF AIR DISINFECTION TECHNOLOGIES
AND FACTORS THAT FACILITATE AND INHIBIT THE IMPLEMENTATION OF THESE
TECHNOLOGIES IN HEALTH CARE SETTINGS IN SUB-SAHARAN AFRICA (SSA)
Abstract
Airborne infections significantly contribute to global mortality and morbidity.
Tuberculosis (TB), for instance, is an airborne infectious disease with the highest global mortality.
The emergence of new strains of airborne infectious diseases is a cause for greater attention. The
COVID-19 pandemic, caused by the airborne Coronavirus, has transformed the world in its entirety, infecting over 100 million people and killing more than two million (by the end of January
2021). These underscore the need for airborne infection controls, especially in a congregate environment- health care facilities, where the risk of nosocomial disease transmission is higher than in other areas.
In congregate settings, increased chances of rebreathing contaminated air increase the risk of nosocomial disease transmission. But air disinfection technology is proven effective in decontaminating room air and reducing disease transmission. Pathogens that cause TB, measles, influenza, Severe Acquire Respiratory Syndrome (SARS), and other diseases are susceptible to air disinfection technology. However, there is doubt around scaled implementation in Low and Lower
Middle-Income Countries (LLMICs).
Like other LLMICs and Sub-Saharan African (SSA) countries, Liberia is impoverished and has a high TB burden. In 2008, Liberia's National Leprosy and Tuberculosis Control Program
(NLTCP) reported a TB occurrence of 108/100,000 population. The World Health Organization
(WHO) annual TB report classifies Liberia among the 30 high TB burden countries. Now that the
ii government is struggling to implement health programs to reduce infections and improve the population's health, understanding the barriers and facilitators to indoor air safety is essential to creating safer health care facilities and other congregate settings.
We conducted a systematic review of the literature to understand air disinfection technology in LLMICs—including SSA countries and Liberia. Dilution, filtration, and ultraviolet germicidal irradiation are the three air disinfection technologies covered in the study. The result of the systematic review found studies conducted in high and upper-middle-income countries but not LLMICs— showing the need for more air disinfection research in LLMICs.
iii
Contents
Part 1: Air disinfection technology and the origin of social suffering in Sub-Saharan Africa ...... 1 Background ...... 2 Introduction ...... 7 Overview of air disinfection technologies ...... 9 Integrating infrastructure design into health care ...... 15 Impoverishment induced by exploitation...... 16 Liberian history and the civil crisis ...... 17 Liberia's health care system, global TB, and the application of air disinfection technology ...... 23 The cost of TB...... 27 The social burden of TB ...... 29 Part 2: Implementation of air disinfection technologies in health care settings in low-and lower- middle-income countries: a systematic review ...... 33 Introduction ...... 34 Methods ...... 36 Results ...... 38 Strength and limitations ...... 46 Conclusion ...... 46 References ...... 47 Appendix ...... 53
iv
Figures Figure 1: Problem and approach ...... 33 Figure 2: Intervention and impact ...... 33 Figure 3: Search strategy ...... 38 Figure 4: Systematic review process ...... 44
v
Tables
Table 1: Final studies included in the systematic review ...... 41
vi
Acknowledgments
I extend my thanks and appreciation to Professor Edward Nardell for accepting and guiding me through all phases of this unique MMSc program. Also, to Alma Adler for leading me through the steps of a systematic review of the literature. Beyond mentoring, you both became friends during a tough period, and for this, I am grateful. This work was conducted with support from the Master of Medical Sciences in Global Health Delivery program of Harvard Medical School Department of Global Health and Social Medicine and financial contributions from Harvard University and the Ronda Stryker and William Johnston MMSc Fellowship in Global Health Delivery. The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard University and its affiliated academic health care centers.
vii
Part 1: Air disinfection technology and the origin of social suffering in Sub-Saharan Africa
Vignette
As hearts raised faster and eyes stare vaguely, the only wish was for the acceleration of daylight. They conjure long-served deities for a miracle. Here, the heart is the organ of judgment; even the most intelligent and experienced remembers nothing. On this day, there could be no wish greater than wishing for a blissful clutch, tightly enveloping and gripping away the beloved ones from the monstrous hands of death.
The carnage unleashed by the horrors of the night is unimaginable. Night has lost its natural role of rest and become the conduit for evil, its presence unleashing fear and uncertainty: will those kids be visited before daylight? Will he come and take them away? And once more, he proved invasive, taking them at his will and pleasure, in different yet predictive forms. All they do is watch, wish, wonder, and weep: will they ever have the chance to say goodbye? Will he take them with a sudden hemorrhagic fever? Or will they go slowly and painfully with congested lungs, struggling for breath while beloved ones watch them with tears eyes? They curse him, so he finally attends a court of moral judgment to argue his case. He laments, “Why me? Why am I not appreciated? Why should I take the blame? I do what is most needed.” He justifies his role.
“I simply helped the poor things die rather than suffer.” He argues that he is the final arbitrator and does the ultimate justice. He continues until his voice becomes faint; “Why do I always visit a single group? Why were they left so vulnerable? Every group has what I like- blood, life, and they all feel what I inflict- pain, terror, and suffering. I knock on many doors, but some are well bolted, so I fail to achieve my other groups’ objectives”.
Some doors are bolted by technology that prevents illness, promotes wealth, education, and proper nutrition, while others deprived of technology are impoverished and predisposed to
1 suffering. Technology has and continues to play a cardinal role in health care. The implementation of air disinfection technology, for instance, prevents the spread of airborne infections, thus saving lives and preventing human suffering. He concludes his defense by saying
“I, therefore, take what I am given- the poor, oppressed, and marginalized. I have become an arbiter of justice and not the monster you consider me to be”. They are shocked and become aware of the social injustices permeating the society and grouping the victims- the most disadvantaged. Those who are farthest away from the continuum of care. Who disease cannot be diagnosed, and care often starts as an emergency case. Indeed, they have been given away, leaving their communities and societies to bear the impact of their passing.
Although the unequal burden of airborne infection remains a significant contributor to human suffering amongst marginalized and impoverished people, air disinfection technologies could control the infection rate, thereby mitigating the suffering endured by vulnerable groups.
Background
Long before the advent of public health as a specialized field of study and practice, the role of contaminated air in disease outbreaks and transmission had a central focus.1,2 In ancient
Greece, drifting from the generally held belief that diseases resulted from supernatural powers,
Hippocrates (BC 460-377) believed that "air, along with water and places"3 played a central role in disease outbreaks.3 Building on Hippocrates' theory, his student Galen (AD 129–199) and a few others postulated that contaminated air was the infectious agent.2 Galen's postulate, widely accepted among scholars and scientists at the time, formed the basis of the Miasma theory—bad air containing particles mainly made up of organic matter transmits diseases.1,2
2
By the sixteenth century, Girolamo Fracastoro (1478 – 1533) had begun arguments that diseases resulted from particles in the air that could be transmitted between people.3 Hippocrates and Fracastoro had opposing views that dominated the scientific arena during the renaissance.
Susan Carr summarizes Hippocrates' postulate of disease causation as "environmental factors dictated the potential for outbreaks and that an individual's susceptibility determined whether he or she would fall ill,”2 and Fracastoro as explaining that "microscopic agents were responsible for disease and that these agents could be transmitted by direct contact, through the air, or by intermediate fomites (inanimate objects such as doorknobs or drinking glasses that harbor infectious disease)."2 Fracstoro's postulate formed the theory of Contagion (i.e., the disease could be directly or indirectly spread between people), and competed with the miasma theory postulated by Hippocrates' student Galen.
The miasma theory prevailed until overwhelming evidence proved that a non-air alternative medium transmitted the infamous 1848 London cholera outbreak.3 Surprising to the
Miasma theorist, the London physician John Snow demonstrated that the outbreak resulted from ingesting contaminants in the municipal water (a public pump). He stopped residents from drinking the water and subsequently removed the pump's handle. Snow's finding inarguably proved that particles called germs were the agents of infections.1,2,3
The germ theory of disease—"that a specific, living, contagious agent was responsible for each infectious disease"3—postulated by Louis Pasteur did not dismiss air in disease transmission. Still, it refuted the assertion that air was an infectious agent for all illnesses. The study of different diseases—including the pathogens' size—would later reveal that particular pathogen could remain suspended in the air and transmit between people.
3
In 1683 the light microscope was invented, revolutionizing the study of diseases.2 As microscopy expanded, the frontier of scientific investigation broadened, pathogens were studied, shedding light on disease causation and transmission. Gradually, public health approaches became more organized, focusing on disease causation and targeting diseases such as Leprosy and plagues.2,3 By the close of the nineteenth century, the germ theory identified the causative agents of malaria, plague, tuberculosis, etc.3
Tuberculosis has existed for over 9,000 years and killed "one out of every seven people living in Europe and America."4 By 1882, Dr. Robert Koch discovered that Mycobacterium tuberculosis caused Tuberculosis (TB). Interest in the mode of transmission grew, with varying hypotheses and beliefs. In 1909, William Osler became one of the first to suggest the disease's transmissibility in the 20th century. He claimed that if uninfected people mix with those infected with the disease, they could become sick. Other scientists supported the transmissibility concept.
In 1920, Devoto wrote that caregivers in health care settings were at risk of contracting diseases.
This concept was proven by Heimbeck, who provided evidence that nurses were at greater risk of testing positive for clinical tuberculosis.5 Over time, the higher risk of disease transmission in schools, prisons, and other congregate settings was established.3
Controlling contaminated air has been of focus in health care. Florence Natengale (1820-
1910) recommended sufficient spacing between hospital beds and keeping windows and doors open to increase ventilation.6 Between 1956-1962, R.L Railey and colleagues proved the transmission of TB via air by exposing guinea pigs to air from a TB ward and quantified infection at the end of the exposure period.7 This was the first comprehensive quantitative study proving human to guinea pig's transmission of airborne tuberculosis infection. Railey's results were so definitive that they aroused interest in controlling disease transmission. Disease control
4 experts ascertained the risk of disease transmission in congregate settings, Railey's work increased the focus on environmental disease controls. Environmental disease control focuses on the disinfection of environmental modes of transmission, such as air.8 By disinfecting air, pathogens susceptible to the mechanism of disinfection become either less or non-infectious.9,10
Air disinfection is becoming a central focus as concerns over emerging diseases continue to rise in the 21st century. Even before the scientific community agreed on the transmission of
COVID-19, twenty-three scientists wrote an open letter to the World Health Organization
(WHO), stressing the need to treat the virus as a highly contagious airborne disease.11 To save lives, they urged following precautionary principle and complementary procedures.11 They further recommended avoiding large crowds and using air disinfection measures as preventative mechanisms against the virus. According to the scientists, the risk of airborne transmission in a group increases in enclosed spaces where occupants breathe contaminated air.11 Since air cannot circulate in enclosed spaces, the risk of transmission of an uncontrolled airborne infection is understandably proportional to the size of the group and the contaminants in the air. Therefore, larger groups with inadequate air disinfection controls are at higher risk of transmitting airborne pathogens in enclosed spaces.
Effective air disinfection mechanisms reduce the transmission of diseases. Ventilation and air purification are two modes of indoor air disinfection. Ventilation is mainly by natural or mechanical means,12 although a hybrid or mixed-methods ventilation system exists, it is not covered in this work. Both ventilation and air purification reduce the transmission of TB, measles, and influenza in buildings. However, each technology has its advantages (applicability) and disadvantages (limitations).12 For example, widely used natural ventilation is dependent on wind energy, limiting its application in climates deprived of adequate wind. Mechanical
5 ventilation is a credible alternative, but its cost and technical details are cumbersome. Air purification by ultraviolet irradiation is independent of wind energy and is easier to install than the mechanical ventilation system,12 making it a viable alternative, but global implementation is low.
Research suggests that air purification could work well and have enormous benefits in
LLMICs. Replicating Railey's research, a team of researchers in South Africa exposed 90 guinea pigs to untreated exhaust air from a TB ward over seven months. The researchers alternated between treating the room air with UV irradiation and keeping the air untreated. The result of the research showed that the technology was 80% protective against guinea pigs contracting TB.13
Though more research is required, including research involving human subjects, UV technology is essential in controlling airborne diseases in some settings. The methodological similarity of the study conducted by Railey in the United States and a similar study conducted in South Africa suggests the global application of UV technology. Unfortunately, many African countries are lagging in technological applications.
Africa's history and political economy explain the underutilization of technology
(including limited air disinfection technologies), inadequate health systems, and high disease burden, especially in Sub-Saharan African (SSA) counties. Countries in SSA are hindered by years of deprivation, exploitation, inhumane colonial rule, and draconian neocolonial acts — including African nationalists' assassinations. Beyond the physical lack of access, deprivation suffered by families, communities, and entire nations promotes what is termed social suffering.14
SSA countries continue to rank high in diseases of poverty — the most common is TB.
Controlling the burden of TB by the application of proper air disinfection technology contributes
6 to reducing the burden of TB and subsequently addresses some forms of suffering created by TB in LLMICs, including countries in SSA.
Introduction
Understanding the effectiveness of air disinfection technologies and factors that facilitate and inhibit the implementation in health care settings is fundamental to controlling nosocomial airborne infections in LLMICs. The WHO Global TB Reports 2019 and 2020 identified more than half of the 30 high TB burden countries in Africa.15,16 Institutional transmission of undiagnosed and untreated TB is known to contribute to the growing number of cases.17,18
Addressing global TB, the WHO 2019 Guideline on TB prevention and control lists administrative, environmental, and personal respirators as the hierarchy of controls.19 Since the development, approval, publication, and roll-out of this guideline, there has been unequal implementation across various regions. Implementing recommendations in the guideline requires substantial resources lacking in many LLMICS, especially in impoverished settings with a high burden of TB.
Today, most countries' national disease burden is predictable—increasing and decreasing with income and governance. Additionally, the political economy is a determinant of health and high disease burden in SSA countries ravished by conflict and low economies. Prolonged instability incapacitates these governments' from maintaining a functional health system. As a result, these governments are heavily reliant on foreign aid and grants, most of which are secured by political and diplomatic relationships with donor countries. The high cost of health programs sometimes requires multiple funding sources and various donors with conflicting priorities. From time to time, donors retrench promised donations or refuse to make future donations when
7 competing interests are not satisfied.20 Drury and colleagues analyze data from 1964-1995 and conclude that US humanitarian aid was politically motivated.20 Politics and the global power dynamics affect the quantity of the grant a country can receive and determines the quality of the health programs the government will implement.
Today's reality is the result of years of resource extraction and geopolitical influences in
Africa. Additionally, this reality is reflected by the Transatlantic slave trade, colonialism, and
(ongoing) neocolonialism.14,21 The Western nations' desperation to continuously extract resources from Africa has led to multiple crimes against Africans—from undermining national democratic structures to shattering systems and instigating crimes against humanity. 14 Africa remains a continent of exploitation through coercion and the removal of democratic governments, resulting in many African governments' inability to provide essential social services to their people. The health system is one of the most affected social services, including the failure to implement global advances in disease control. It is a logical pursuit to investigate the implementation of said advances in LLMICs (including SSA).
This work explores the utilization of air disinfection technologies across different regions. Because the risk of nosocomial infection is high in HCFs, it is the primary area of interest. The safe integration of air disinfection technology into the design of current and future
HCFs is a treasure chest for controlling nosocomial infections.
The work begins with an overview of air disinfection technology followed by the global application and perception. Finally, it discusses the burden of nosocomial disease (specifically
TB) in the context of SSA and Liberia. All through, it gives a synopsis of the relevant history, political economy, and the current health conditions in Liberia. TB is the airborne disease of focus, based on the availability of literature and the global burden.
8
Overview of air disinfection technologies
Air disinfection technologies improve indoor air quality (IAQ) by moving or disinfecting large air volumes in a building. Maximum air changes and inactivating airborne pathogens are central to these technologies. As safe air moves into a building and contaminated air is forced out, a process termed dilution, pathogens in the medium are reduced or inactivated. Pathogens also could be inactivated when contaminated air circulates and filters through mechanical filters, reintroducing clean air to the room, a process called filtration. Under well-designed conditions,
UV irradiation kills pathogens. Together, dilution, filtration, and Germicidal Ultraviolet (GUV) are three of the most effective air disinfection technologies.22
Dilution is widely achieved by natural ventilation. Natural ventilation relies on wind movement to continuously bring fresh air from outside into a building and force out contaminated air. Its success “depends on the climate, building design and human behaviour.”12
Natural ventilation is commonly used in low and lower-middle-income settings because it can be done by merely keeping windows and doors open (an economical advantage).12 Sources of ventilation (windows and doors) help increase access to daylight and save energy. As James
Atkins explains, the success of ventilation mechanisms depends on the ventilation rate, airflow direction, and distribution pattern.12
a. Ventilation rate is the frequency of air change within a specific time to maintain clean air
by continuously removing unclean air from a space. Commonly used measures of
ventilation rate include L/sec. per occupant and room air changes per hour (ACH). These
are harder to measure for natural ventilation compared to mechanical ventilation.12
9
b. Airflow direction is the essential one-way flow of air that ensures contaminated air is
removed and replaced by clean air in a uniform pattern. Proper one-way flow prevents a
backward movement of air that could reintroduce contaminants into the room.12
c. Air distribution pattern keeps air in various parts of the building clean. Because there are
multiple areas of a building, properly distributing air prevents air in some areas of the
building from being stagnant.12
However, inclement weather, security risks, and superstition—mainly at night, lead to shutting doors and windows and limiting natural ventilation.23 Keeping doors and windows closed to prevent intrusion and maintain acceptable room temperature reduces wind flow and increases rebreathed (mostly contaminated) air in a room.23 In LLMIC settings that depend on natural ventilation, the high crime rate caused by harsh living conditions necessitates shutting windows and doors, limiting the average ACH in a building. Geographical regions with torrential rainfall or severe cold and unaffordable high heating costs also require the closure of windows and doors. Heavy annual rains often forced countries reliant on wind energy to take measures that limit the technology's effectiveness.
Global warming hinders the application of natural ventilation. David and Gertler's use of models to predict energy consumption over the next decades due to global warming,24 signifies the modulating role of increasing temperatures on people and society. Increases in the average global temperature promote air-conditioning systems,24 that require the design and modification of buildings to prevent external air from entering or leaving through windows and doors. For air conditioners to function effectively, room air circulates within the room without mixing with external air. Under these conditions, ACH (i.e., between internal and external air) reduces, and contaminated air fraction increases.
10
Mechanical ventilation is used as an alternative and widely implemented under conditions that do not favor natural ventilation.12 Mechanical ventilation uses mechanical fans installed in windows or walls and air supply ducts to mix air in a building continuously.12 Its effectiveness relies upon the careful design and how the climatic conditions affect the system.
Balanced air exchange is essential for proper functioning, and adequate room air is balanced in both negative and positive pressure designs by well-designed systems that interchange the air.
Rooms are often designed with slightly more pressure in one direction according to their purpose.12 Negative pressure designs apply to rooms with activities that generate pollutants.
These include industrial rooms where clean processes are required. The Center for Disease
Control (CDC) recommends a 2.5 Pa negative pressure for rooms generating airborne contaminants than the corridors.25
Room pressure is essential in controlling nosocomial infections. Hospital isolation rooms are under negative pressure to prevent contaminated air from leaving the room and spreading to the outside. Hospital (isolation) rooms that treat TB, COVID, and other infectious diseases are under negative pressure. Positive-pressure rooms prevent contaminants from entering clean rooms. Surgery rooms are under positive pressure to keep it sterilized.
Mechanical ventilation systems fitted with Highly Effective Particulate Air (HEPA) filters remove contaminants from the circulating air and allow only clean air to return to the room. HEPA filters are up to 99.97% efficient in removing pollutants of ≥0.3 μm in diameter.25
It is favor as a convenient mechanism in disinfecting hazardous rooms, especially in health settings.25 The combination of HEPA filters in a ventilation system and directional airflow (that forces contaminants to move in the direction away from people) protects non-infected people on
11 hospital wards.9 Carefully designed mechanical ventilation systems are independent of wind direction and temperature; hence their efficiency is independent of natural forces.12
Complex mechanical ventilation systems are often designed differently from the buildings—requiring highly trained technocrats for both installation and maintenance of the often-pricy system. Beyond installing mechanical ventilation systems, its complexity further complicates usage by owners and residents of buildings—the resulting frequent damages also increase the often-high cost of repairs. All air ducts must be kept clear. Clogged air ducts affect the air supply or removal and the desired negative or positive pressures of rooms. Both technical and practical requirements limit the usage of mechanical ventilation systems, and in some cases, restrict their performance compared to natural ventilation.12
Hospital-based studies conducted in Lima, Peru, found that naturally ventilated rooms of all forms had more ACH than the recommended 12 ACH for mechanically ventilated rooms.10
Regular styled facilities with natural ventilation rooms maintain 28 ACH, and facilities constructed in the 1950s with high ceilings and large windows maintained 50 ACH.10 All forms of ventilation have limitations. From the requirement of wind to the complexity of designs, natural and mechanical ventilation systems are not always practical. Supplemental and alternatives technology like UV lights compensate where the efficiency of ventilation systems is doubtful or nominal.12
Even before investigations began to apply UV irradiation as a supplemental air disinfection technology, its use in water treatment and surface disinfection was widely practiced.26 UV disinfection was a breakthrough in photobiology. Downes and Blunt's 1877 experiment proved exposure to sunlight could prevent the in-vitro growth of microorganisms.27
According to the two researchers, the success depended on the "intensity, duration, and
12 wavelength."27 Although photobiology continued after Downes and Blunt's work, much interest arose in 1935 when Wells and Fair proved the concept of airborne infection and the efficacy of
UV in controlling airborne pathogens.28 Together with the global increase in TB cases in the mid-twentieth-century, focus shifted to various applications of U.V.26
The results of numerous researches proved the relevance of UV light in air disinfection, but genuine concerns over invasive UV irradiation and its carcinogenic effects stalled implementation.29 Many people raised concerns about UV exposure as an uncontrolled hazard in public places and in congregate settings — where the possible application is most expected.
Subsequent studies found that UV of specific wavelengths could safely disinfect occupied rooms without significant risk to occupants. Prominent among these was a double-blinded placebo study called the Tuberculosis Ultraviolet Shelter Study (TUSS), conducted in fourteen homeless shelters in the United States to prove the safe application of UVGI in air disinfection.30 Although the research reported minor eye and skin irritations, there was no statistical significance between symptoms reported during active and placebo time. The single keratoconjunctivitis case resulted from improper exposure (a bed placed directly under the irradiance zone).30 However, UV's safe application must follow guidelines containing instructions from installation to the selection and placement of furniture.31
Technical guidelines specify the safe design and application of UVGI. The United States
CDC's National Institute for Occupational Safety and Health (NIOSH) has developed a technical guideline for the safe use of UVGI and emphasized the benefits of its implementation in health care facilities, especially where the risk of undiagnosed or untreated TB exist.31 Although no longer current in terms of some details, such as dosing strategies, the NIOSH guideline serves as a convenient review of the technology up to its publication in 2009. According to NIOSH, the
13 effectiveness of upper-room UVGI systems is dependent on the average UV irradiance in the room, vertical air mixing, ray length, the efficiency of fixture design, and maintenance.12,31
The NIOSH guideline recommends specific upper room UV average irradiance (dose) requirements for optimal GUV function based on chamber studies funded. More recently,
Rudnick emphasized the difficulties in determining the average upper room UV irradiance in a room suggested by NIOSH.32 He argued that upper room GUV's effectiveness is determined predominantly by 1) total GUV fixture output and ray length – the distance UV rays travel before being absorbed by walls, ceilings, or objects; and 2) the vertical air mixing in the room.32 Based on Rudnick's approach, Mphaphlele and colleagues reported the effective upper room UV dose as either a total fixture UV output (rather than electrical or UV lamp wattage) of 15–20 mW/m3 total room volume or an average whole-room UV irradiance (fluence rate) of 5–7 mW/cm2.13 A second unpublished repeat study found equivalent efficacy at 1/3 less total fixture output, that is,
12 mW/m3 room volume.13 This is the dosing strategy currently being recommended, based on limited numbers of real-world studies.
Even during the application of UV technology, air movement is critical. Vertical air movement moves non-irradiated air in the lower non-irradiated zone of the room to the upper irradiated zone. In occupied rooms, body heat generates significant vertical convective air mixing, but this is often supplemented by low-velocity ceiling fans, mechanical HVAC systems, and other air-moving devices.12 Rapid air turnovers between the upper and lower room reduce resident time. However, more passes per unit time, resulting in similar microbial inactivation both in theory and chamber studies. Ideally, contaminated air rises into the irradiated zone. It is completely decontaminated in one pass, but high levels of air disinfection likely depend on repeated exposure due to good air mixing.12,22
14
Integrating infrastructure design into health care
The role of infrastructure design in the environmental control of disease is gaining traction, prompting innovative modeling and remodeling of public facilities. Despite the high cost of infrastructure designs and the accompanying technology, the benefits inspire organizations to venture into nonprofit work. Prominent is the Boston-based architecture company Mass Design.33 The acronym "Mass"—Model of Architecture Serving Society reflects the aspiration to work for communities for little personal gain. Over the years, the group has worked with governments to develop projects that reflect the communities' aspirations.
Governments, health organizations, and engineering companies on this journey equate proper design to the safety and dignity of beneficiaries.
Mass Design Group summarizes the concept of decent construction in its publication
“Justice is Beauty,” laying out numerous projects with a central and common human philosophy of social justice. The Butaro Hospital in Rwanda is one of those projects that epitomizes this philosophy, as shared by the Rwandan government and the international health/charity organization Partners in Health (PIH). Commending stakeholders and Mass Design for the project, Chelsea Clinton, Vice President for the Clinton Foundation, wrote:
It stands as a testament to what is possible when the design is based on the concept
of the practice of dignity in service to what we all would love for ourselves and
our families, anywhere in the world … the Butaro campus also proves what is
possible when inequality and inequity are addressed ferociously.33
The Butaro facility remains a reference for integrating local aspiration and cultural dignity into a twenty-first-century health facility to enhance quality care (including care for pediatric cancer). MASS Design's unconventional design of the TB ward of Butaro hospital, such
15 as arranging beds to face the windows and giving patients access to sunlight, esthetic landscape, and other natural features,33 reflects the integration of culture dignity design. In addition, the success of tailored projects in Haiti, Liberia, and the US illustrates the benefits of involving stakeholders from the design to the project's execution phase.33 Respecting the cultural heritage of the direct project beneficiaries encourages their participation.
Mass Design severally initiated projects discussion and sometimes commenced projects independent of initial financial investment from the beneficiaries.33 This initiative supports countries with low economies. Such an approach is essential for African countries with an ever- growing dynamic population that necessitates more infrastructure.
Impoverishment induced by exploitation.
Africa's history contains details on the origin of its impoverishment, beginning with the
Trans-Atlantic slave trade (and continues with its relics). Nineteenth and twentieth-century accounts reveal the extent and ripples of the slave trade on the African continent. From the inception of the trade around 1619 to the proclaimed end, millions of productive Africans worked an estimated 222,505,049 productive hours in Europe and America, calculated on the US minimum wage equivalent to 97 trillion dollars.34 Africa was a feasting ground for exploits.
Meanwhile, Europe and America continued to progress while Africa, the builders' (enslaved laborers) home, became impoverished and dependent.
As western plantations and industries grew, so did the demand for enslaved people.
Consequently, slave traders increased the supplies of enslaved people to meet the labor demands of plantation and industry owners. African children born to enslaved people became the property of enslavers. It seemed like an endless visual circle. Even after the proclaimed end of slavery,
16 enslaved people remained enslaved. Only free men could not be enslaved. Such a contradiction between the proclamation to end slavery and the reality of freedom makes it difficult to put a realistic date to the practical abolition of slavery.
Liberian history and the civil crisis
Liberia started as a home for formerly enslaved people taken from the United States of
America (USA). The trans-Atlantic slave trade sheds light on the early history and formation of
Liberia. As people enslaved in the US grew in numbers and consciousness, they began various forms of struggles that frightened enslavers.35 Herbert Aptheker explains that the struggle for freedom took eight forms, four (strikes, sabotage, antislavery agitation, and revolts) instilled fear in enslavers.36 The actions of enslaved people, coupled with increasing pressure from humanitarians calling for an end to enslavement, led to abolishing the slave trade.
Shortly after the proclaimed end of slavery, white supremacists began calling to remove ex-enslaved (now free) people from North America,37 where many were born and have built.38
Although illogical, supremacists fear ex-enslaved people would grow in numbers and compete for resources (to which they were well entitled). These baseless claims engender proclamation to move free men (Black-Americans) to Africa. Historians challenge the concept that this was a resettlement project on account that people brought to the shores of West Africa in the nineteenth century was a way of fulfilling white supremacist quest to dispose of the ex-enslaved people,37 but not necessarily to reunite with relatives or return to the place of origin.
With the aid of a US naval vessel, a purportedly US philanthropic group called the
American Colonization Society (ACS),37 acquired land in Cape Mesurado, along the West
African coast. It transported the first 88 persons—known in Liberian history as the Americo
17
Liberians. Years later, they formed a little enclave of mainly coastal land and declared independence on July 26, 1847, to prevent France and Great Britain (each with colonies nearby) and to ensure economic sovereignty.37,39
Though the US did not recognize Liberia's independence until 1862,40 and the US maintains that Libera was never its colony, the relationship between the two countries was unlike any in the region. At the core of this relationship was US interest, notably, the Firestone Rubber cooperation and other subsidiaries holding significant assert in Liberia. Businesses owned by US companies and direct government interests (including military assets) across Liberia yielded infinitesimal reciprocal benefits.39,41 In the years that followed, the US ignored the consequences of steps taken to protect her interest and dominate Liberia, revealing the US's imperious immediacy of interest.42
Moreover, the previously mentioned haphazard transportation of free men to Liberia's shores broiled into a series of conflicts between the natives and the settlers (Americo-Liberians).
This conflict continued long after independence.43 After that, deep internal division and marginalization fermented a strained relationship between descendants of the Americo-Liberians and the natives, worsened by geopolitics during the cold war.37 Contemporary history exposes international conspiracies and exploitation of Liberians' fluid relationship. This conspiracy contributed to a prolonged civil crisis that derailed Liberia's growth and development.
State-building involves unifying groups with different ideologies under a common rule, hence the inherent potential for future problems. Often, weaker groups are dominated and subjected to the regulations (that becomes state laws) of the more influential groups. Resources strapped from outlying regions support the state in which principles the victims do not ascribe.
18
State-building is sometimes a coercive process. But this is not new to history, as Max Weber describe state building:
In historical perspective, state-building has generally been a coercive and often a
violent process. State building involves imposing a unified, centralized state and
subjugating peripheral regions, securing border areas, and imposing regulation,
institutions, taxation, and control. This has been a violent process because it
threatens the interests of recalcitrant actors, and it encounters outlying resistance,
which must be suppressed.44,45
Coercive state-building was a common practice in Africa. According to Achille Mbembe, it dates from colonization. In one of Marta iñiguez De Heredia's publication, he writes, "For
Achille Mbembe, rule and states in Africa were consolidated during [colonization] through two different forms of violence, one of conquest under a claim of 'right to rule' and another of
'domestication' under the discourse of [civilizing] the natives."44,46 In Liberia's formation, settlers formed a state on land occupied by natives without considering these natives as equals.40
Following independence, the natives were excluded from government, subjugated, and violated by the Americo Liberians, who replicated the subjugation and pain they endue in
America.40 By annexing native lands and extracting their resources, the colony expanded its wealth and territory.37,43 In 1904, there was a decision to bring the natives indirectly with the government,47 but fruition was not until several years. In 1946, two years after William V.S.
Tubman was elected as president (in 1944), natives could vote in the presidential and legislative elections for the first time, marking a gradual twist in the country's political landscape.47
Natives could not access social institutions run by the government and rarely admitted into academic institutions built by the settlers without renouncing their traditions. Constrained,
19 natives began converting to Christianity (the colonist religion) and giving themselves the settlers' surnames to gain admission into academic institutions. Some natives finally acquired formal education. Literacy gradually replaced ignorance, promoting aspiration of greater involvement in affairs of the state. However, the slow pace of inclusiveness was unbearable, creating an aura of disenchantment. The frustration degenerated into a series of historical events, including an infamous riot on April 14, 1979.47
The 1979 Rice riot, as it is termed in Liberian history, was initially staged to protest the increase in the staple food price but became bloody when police turned their guns and fired into the crowd of protesters, killing about 41 people.48
Beyond a single historical event, the riot was the surface of a constellation of socioeconomic and geopolitical instability. It revealed a deep struggle for economic sovereignty and exemplified the historical divide between the natives and Americo-Liberians. Increasing the price of imported (mainly American parboiled) rice would support local production, promote self-sufficiency, and limit international influence.48 Away from home, self-reliance was not welcome by the traditional allies of Liberia. President Tolbert was steering away from conventional capitalist ideas, fueling an international conspiracy that would later transcend the riot and spiral into a political enigma for his government.35
Opposition politicians in Liberia exploit the natural human tendency to resist change label the price increase as unjust. This price increase was exacerbated by disenchanted consumers lamenting the inability to purchase the staple food's preferred brand (American parboiled rice), setting the stage for escalation. Politicians and activists subsequently brought large numbers of aggrieved Liberians into the street to stage the massive street protest.48
20
The Americo-Liberians elites were by all measures educated, prosperous and influential.47 They controlled the government, the national resources, and the economy. Due to their affluence, they were unaffected by the increase in the cost of rice. In addition to being unfair, this hierarchy promoted structural violence against the natives, creating a soft spot for international conspiracy.
In 1980, a coup d'etat ended the long reign (1847-1980) of the Americo-Liberians.47
Although there have been disputed accounts of the masterminds of the coup that killed the then
Americo-Liberian president William R. Tolbert Jr, Master Sergeant Samuel K. Doe, a native of the Arm Forces of Liberia (AFL), claimed responsibility for the coup.47 Suspicion of western powers' involvement in the coup originates from records of policy dissatisfaction with President
Tolbert's administration.35 Also, President Tolbert had maintained views different from Western countries during the Cold War. The Cold War marked the epoch of assassinations and overthrew progressive African leaders for steering away from Western ideologies.14,35 For example, when
Patrice Lumumba sought assistance from the Soviet Union to resolve domestic challenges,
Belgium and the US were furious and subsequently facilitated his assassination.
After the 1980 coup in Liberia, the ruling military junta tried and executed high-ranking members of Tolbert's government for corruption and malpractices. The junta, a darling of several foreign powers, including the US,35 was corrupt and tribal (largely composed of President Doe's
Krahn ethnic group). Even after the junta became a civilian government in 1985,47 they continued to marginalize other ethnic groups and prosecute ex-government leaders. Nepotism and despotism gradually set the stage for resentment that soon translated into action when
Charles G. Taylor launched a rebellion from the north of the country.35
21
Shortly before the rebellion, Charles G. Taylor (an Americo-Liberian descendent with a good rapport with the natives) was arrested in the United States on allegations of corruption and embezzlement. 35,49 Taylor reportedly escaped the Plymouth County Correctional facility, a maximum-security prison in Boston, Massachusetts, where he was awaiting extradition to
Liberia on charges of embezzlement of funds from the Liberian government. 35,49 Contrary to what was officially reported by the US authorities, Taylor severally denied his escape and stated that he was escorted out of prison by men acting on the very high authority of the US government. 35,49 By this time, the relationship between president Doe, the US, and other western allies worsened. 35 In 1989, with the aid of foreign powers (mainly Burkina Faso and Libya) and international business firms in France and Britain, 35 Taylor started an arm rebellion against the government. By this time, many Liberians were disenchanted with President Doe's governance and hoped Taylor could bring an amicable new leadership.
After Taylor was elected president in 1997,47 hostilities were temporary, but hopes for rebuilding faded when hostilities resumed. A series of rebellions involving different actors continued between 1999 to 2003. According to local and international reports, external aid to
Liberian rebel forces seeking to oust the elected leadership exacerbated the conflict.50,51 Foreign governments allegedly provided support to the various arm factions involved in hostilities.
Human Rights Watch (HRW) accused neighboring Guinea of supporting the rebels Liberian
United for Reconciliation and Democracy (LURD), fighting against the government between
2000 until Taylor's exile in 2003.50 The Liberian government also accused the then US government of arming the rebels through the Guinean army.51
Following nearly two decades of regional instability, Taylor was indicted for aiding and abiding rebels to commit crimes against humanity during the Sierra Leonean civil war, arrested,
22 prosecuted, found guilty by the International Criminal Court (ICC), and sentenced to prison for
50 years.52 Taylor's incarceration ended the armed conflict, but the impacts from the crisis remained visible.
Ousting Taylor was protracted; the US and United Nations' sanctioned Liberia and deprived the country of aid, which led to essential services being the worst in the nation's history.
By the end of the conflict, thousands of people were killed, and many more were displaced.
Social services collapsed and needed to be restarted.53 The action of external actors was not without consequences for the country. Alienating Liberia in international trade eventually led to a total economic breakdown. For a country that relies on exports of natural resources—mainly iron ore, rubber, and timber for national revenue—the political and economic instabilities were a nightmare. As a result of the instability, the major iron ore companies closed. The largest rubber plantation (Firestone) previously accused of exploiting Liberia's government and people,54 was unregulated. Liberia's high dependence on concessions made it impossible to restart the economy during a period of instability and economic sanction.
The basic component of the health system was severely affected. The lack of "Staff, stuff, space and system"55 created what Paul Farmer later described as a Clinical Desert.56 All regions
(including the capital city) of Liberia were affected. Even the national referral health facility
(John F. Kennedy Memorial Hospital) was understaffed, unequipped, and poorly maintained.
Public health was at its worst, and infectious disease spread at an alarming rate.
Liberia's health care system, global TB, and the application of air disinfection technology
After 14 years of civil war, health care institutions and programs were nearly non-existent in Liberia. The dysfunctional system failed to address the people's most critical health needs,
23 leading to a high disease burden and increased vulnerabilities to emerging diseases.56 Infant and maternal mortality skyrocketed as non-communicable diseases became more prevalent. The
National Leprosy and Tuberculosis Control Program (NLTCP), established in 1989, was completely disrupted by the civil crisis, contributing to the high TB burden in Liberia.57,58
TB is an infectious disease with the highest mortality among adults,15 surpassing
HIV/AIDS. It killed 1.6 and 1.5 million people in 2017 and 2018,16, respectively— higher than the 2018 population of Trinidad and Tobago.59 At a 2017 UN conference, governments and multinational organizations agreed that halting the epidemic required a global response and coordinated strategy. Consistent with the Sustainable Development Goals (SGD) number 3.3 that calls for an end to TB and AIDS by 2030,60 they developed the Find, Treat, and End TB strategy to promote global detection and treatment.15 One year after the conference, a tiny reduction in
TB cases and a 5 billion gap in funding cast doubt on reaching the WHO's targets. But gradually, nations and multinational organizations became more aggressive and are achieving improvement in global TB programs.15,16
In 2020, the WHO reported that a consistent global response is slowing TB transmission, increasing case detection, and improving preventive actions.16 Fourteen million people accessed quality treatment between 2018-2019, and prophylactic treatment reached a record high of four million. Patient care reached 6.4 million in 2018 and seven million in 2019. The WHO End TB strategy target an 80% yearly reduction in the TB incidence per 100,000 population.16 Many countries have not achieved the target. The cumulative reduction between 2015-2019 was 9%, below the targeted 20% by 2020. Regional data shows the disparity in improvement. The
European region excellently achieved 19%, the Africa region made a considerable improvement
24 of up to 16%, the Eastern Mediterranean region just 8.7%, while South East Asia had 6.1%, and other WHO regions had 3.5%.16
The SARS Coronavirus II (COVID-19) impedes global TB programs and threatens to reverse the gains made since 2015.16 Dr. Tedros Adhanom Ghebreyesus, Director-General of the
WHO, said in the WHO 2020 report that "COVID-19 demonstrates that health is not only an outcome of development: it is also a prerequisite of social, economic and political stability".16 In several reports, the WHO has restarted what has been told by public and global health experts — that eradicating TB requires addressing other inequalities. As a co-infection, TB killed 208,000
HIV-positive people in 2019.16 The UN Secretary General's 2020 TB report recommends coordination to fight against TB. The report contains "10 priority recommendations:" 16
1. Fully activate high-level leadership to urgently reduce TB deaths and drive
multisectoral action to end TB
2. Urgently increase funding for essential TB services, including the health workforce.
3. Advance universal health coverage to ensure all people with TB have access to
affordable quality care and resolve underreporting challenges.
4. Address the drug-resistant TB crisis to close persistent gaps in care.
5. Dramatically scale up provision of preventive treatment for TB
6. Promote human rights and combat stigma and discrimination.
7. Ensure meaningful engagement of civil society, communities, and people affected by
TB
8. Substantially increase investments in TB research to drive technological
breakthroughs and the rapid uptake of innovations.
25
9. Ensure that TB prevention and care are safeguarded in the context of COVID-19 and
other emerging threats.
10. Request WHO to continue to provide global leadership for the TB response, working
in close collaboration with the Member States and other stakeholders, including to
prepare for a high-level meeting on TB in 2023 that aligns with the high-level session
of the General Assembly on universal health coverage also to be held in 2023.
Universal health coverage (UHC) has also been highlighted by health and human rights advocates and the WHO as a permanent solution to health inequalities. Tedros Adhanom
Ghebreyesus, Director-General of WHO, reecho this message when he encouraged nation-states to aspire to UHC as a bastion in creating a dynamic primary health care system that would strengthen the fight against all diseases.15 Health leaders believe that alleviating human suffering involves addressing the general burden of diseases. Dr. Ghebreyesus's statement resonates with claims that general health inequalities fuel the global TB prevalence, a plausible explanation for the highest-burden of TB in LLMICs.15
Addressing skewed prevalence and mortality in specific populations requires working closely with the people. The WHO Civil Society Task Force on TB has worked closely with the local communities to address TB-related challenges.16 Conditions promoting the spread of TB vary, and so are members of the countries or regions that understand those conditions.
Among the many challenges faced by LLMICs, impoverishment hinders building and maintaining efficient health systems. Heavy reliance on external sources of funding, including international donations and grants, limits the government's control of the health systems and programs. The often insufficient health budget is inadequate to deliver efficient and equitable health programs that address the disease burden. Liberia's health programs, for instance, rely
26 upon international aid and international non-governmental organizations (INGOs) to meet the inhabitants' health needs.57 Before developing the Liberian National Health and Social Welfare
Policy and Plan, donors and INGOs worked on a particular short-term project that was not the government's priority. Working in silos constrains governments in combating diseases like TB, which requires a continuum of care.
The cost of TB
The cost of TB varies with the susceptibility to treatment. Drug susceptible TB is often treated with antibiotics and costs less compared to Drug/Multidrug-resistant (DR/MDR) TB that requires more extensive treatment. The term DR/MDR-TB refers to the strain of mycobacterium resistant to one or more medications/antibiotics. DR/MDR TB could be transmitted between people or result from incomplete treatment of drug-susceptible TB. This form of TB is difficult to diagnose and treat. The WHO guidelines require bacteriological confirmation of MDR/RR-
TB.19 Even after diagnosis, treatment could last from nine to twenty months and requires different antibiotics. Poor diagnosis and incomplete treatment are high in LLMICs, contributing to the higher number of drug and multidrug-resistant TB.17 The difference in DR/MDR TB cases between LLMICs and high-income countries makes the disparity in access to care visible. The severity of MDR-TB attracts global attention, as highlighted in the UN Secretary General's 2020
TB report titled Address the Drug-resistant TB Crisis to close persistent gaps in care.61
The cost of treating TB varies from free in Massachusetts, the USA, to catastrophic in
India's Puducherry district. The WHO defines the catastrophic cost of TB as greater than 20% of the annual household income and aims to eliminate it by 2035. 16 In the Puducherry district research, Thirunavukkarasu Prasanna and colleagues found the average out-of-pocket
27 expenditure for a household was $8,198 for a single case.62 The WHO also reported that no TB- affected country had stopped catastrophic cost.16 Of the 17 countries that completed the national survey of cost faced by TB, 49% of the household were affected by catastrophic cost. Drug- resistant TB is even higher— 80% of households with DR-TB suffered catastrophic costs.16 LLMICs are mostly affected because of the higher prevalence of TB. High indirect costs may affect patients, even if the cost of direct TB care is free. A study conducted among 196 TB patients in Uganda found that pre-diagnosis cost around 20% of the household income.63
The WHO predicts an astronomical increase in TB deaths if diagnosis falls by 25-50% in
2021.17 Between January to June 2020, there was a low detection in the highest-burden countries, a stark contrast to the increase in cases detection since 2015. 16 The report projects that within three months, there could be between 0.2-0.4 million deaths and about one million deaths per year until 2025. 16 High demand for resources to tackle COVID-19 resulted in the reallocation of human resources, diagnostic machines, and dedicated TB clinics. 16 Overall, simultaneously addressing TB and COVID-19 led to a decrease in the global capacity to adequately address TB.
16 This change, plus the loss of needed social facilities and increasing poverty, undermines the gains to end TB. 16
Diseases are often opportunistic, affecting deprived and exposed populations. The inability of LLMICs to provide the basic social amenities influences the rapid spread of disease and serves as a barrier to treatment.14 Although TB is curable and eradicable, simply giving medication to infected patients is insufficient. Effective care requires treating the disease and the provision of access to social services. Access to basic social amenities defines the quality of life; a lack thereof exposes a person or population to poverty and its consequences.
28
The social burden of TB
The catastrophic cost and poor access to services are contributing to incomplete TB treatment among uninsured low-wage earners.63 Occupation and income influence the judicious decision between seeking treatment and meeting social obligations. The patient's social obligations always supersede when pitted against the high cost of medical intervention. This results in patients seeking alternative health care. Furthermore, inaccessibility to modern health care and the lack of diagnostic equipment promotes a recourse in treatment. As health is a fundamental human right, the patient's inability to attain the highest quality of care threatens their absolute right to existence.14
Inaccessible care indicates roadblocks in SDG3.8 that aim to achieve universal health coverage by the end of 2030.60 Social status and occupation should not be determinants of health or limiting factors to the quality of care. The SDG10.2 goal of empowering and promoting the social, economic, and political inclusion of all by the end of 203060 reflects a global perspective on the role of inequalities in the burden of disease. Global inequality is driving DR/MDR-TB among impoverished patients.64
Farmer and Mukherjee argue that underlying biosocial forces are the primary determinant of health and health-seeking behavior.14,65 They and other scholars premise their position on evidence across all continents, from the homeless in the USA, vulnerable African migrants crossing into Italy, to those rural communities in Liberia lacking paved roads and shut-off from the much-needed social services. Unlike the prevalent assumptions that geography and traditional belief are the primary determinants to seeking healthcare, the overwhelming evidence shows that access to resources is the most important determinant. 14,65 If medical and non- medical services are accessible and affordable, patients are more likely to seek treatment.
29
In her book, An Introduction to Global Health, Mukherjee explains that if systems cater to the health and biosocial needs of the sick, there would be a significant increase in hospital visits and an increased uptake of modern medical intervention.66 Mukherjee’s argument infers that other factors, such as physical access, hinder access for rural community dwellers.
Inaccessible communities' geography and their development restrict travel across long distances to foot, a difficult journey for the sick. Mukherjee noted that "while knowledge of the availability and the potential benefits of care [modern medicine] may increase people's utilization of services, demand creation program often overestimates a person's agency and underestimate the barriers to care."66 For a peasant whose daily meal depends upon plowing the soil, a ten-hour walk to the hospital is worse than the ailment itself, serving as a push factor in seeking alternative treatment, usually within easy reach.
Other works of contemporary researchers and academics further ground our argument and provide evidence that access to quality care is a modulating factor for many diseases. In his book Infections and Inequalities, Farmer argues against claims that high disease rates and low adherence to treatment within some communities are due to beliefs held by the sick.67 He writes of critics who linked disease burden to native beliefs, patient ignorance, and modern medicine opposition. Farmer terms these "immodest claims of causality" and argues that biosocial barriers, seemingly insurmountable yet ignored, prevent access to care.67
Critiques' propagation of erroneous explanations for low medical uptake and the high burden of disease is an attempt to reconstruct reality and distract attention from the difficulties faced by those living with the conditions. Berger and Luckmann's concept of the social construction of reality explains the actions of these critiques.68 The authors claimed that "Society is a human product. Society is an objective reality. Man is a social product."68 This explains the
30 societal construction and typification of stereotypes. The constructed stereotype that a specific group will not seek care permeates the discourse around many ailments, including HIV/AIDS,65 was initially constructed to avoid the responsibility of providing the necessary support to those afflicted. The prevalence of this stereotype is widespread and structural.
TB causes suffering at the levels of the individual, family, and community. It forces groups to reallocate resources to treat the afflicted. Even worse are the stigmatization, and the lack of support for those with TB.69 Suffering exclusion from family and friends redefines suffering in the context of physical and psychological pain. The extent or consequences vary from person to person based on the individual ability to withstand, amongst others, a certain amount of societal exclusion. Moreover, beyond the patient's suffering as individuals, loved ones and associates (society) also suffer.
Patients and their relatives' social conditions and emotional state have received insufficient attention in the treatment regime. Traditional medicine practices focus on the patients' disease state while insufficiently offering care to the community's social conditions.
Kleinman draws on the neglect of cultural forces contributing to social suffering in several writings and emphasized the cultural intricacy and resulting mental health consequences.70 Also,
Kuah-Pearce and his colleagues present social suffering as a set of interdisciplinary ideas of basically "health, social, subjective and spiritual problems."69 They argue that much of human suffering originates from the "social world and societal consequences […] and lastly, social suffering points up the disturbing but crucial reality that the policies, programs, institutions, and practices developed in responding to the suffering, also contribute to suffering."69
Liberians are both culturally and interpersonally interwoven. Such a close-knitted association promotes the common tendency (especially among community dwellers) to care for
31 their members. In times of illness, this association plays a pivotal role in caregiving, even amongst non-biological relatives within a community. Exposure to disease is the least daring they displayed. The willingness to sell personal belongings or even deprive their kids of having a healthy meal to raise money to support their community members is unbelievable. Other benefits are uniting group members—"pain and suffering are always interpersonal conditions that bridge the individual to the collective."69 Confronted by suffering, families amalgamate, empathize with the sufferers, bridge failing relationships, and promote long-term bonds within the community.
The difficulties faced by the government of Liberia in meeting the health needs and providing adequate social services create a climate where TB can thrive, as translated by the high occurrence of the disease in the country. Liberia is one of the 30 high TB burden countries. The
WHO estimated the occurrence of TB in Liberia as 308/100,000 population in 2019.15 However, the Liberian government's capacity to independently invest in more treatment is low. Therefore, it is prudent to contain further spread while addressing the current burden of TB. The spread of
TB in congregate settings is rapid, hence the need for action that protects people in this area.
Liberia's low economy, health system vulnerabilities, security, and lack of social amenities necessitates innovative disease control solutions. The proper utilization of air disinfection technologies will reduce the transmission of susceptible airborne pathogens, especially in congregate settings, and hold promises to protect against emerging diseases at no additional cost. Beyond Liberia, LLMICs could invest in research and implementation of the technologies to control infection risk facilities.
Therefore, it is prudent to conduct a systematic review of the literature on the application of air disinfection technologies in Low- and middle-income countries to understand the implementation of air disinfection technology in HCFs. The result of this systematic review will
32
serve as a basis for an informed decision on investing or divesting in air disinfection research and
application in LLMICs.
Figure 1: Problem and approach
Challenge/problem Approach Causes • A high number of airborne • A systematic review of
infections in LLMICs lead to • Inadequate disease the literature on air disinfection studies in social suffering & control procedures Impovershment LLMICs vs other regions
Figure 2: Intervention and impact
Air disinfection technology
Reduce institutional transmission of airborne diseases
Reduce human suffering caused by airborne diseases
33
Part 2: Implementation of air disinfection technologies in health care settings in low-and lower-middle-income countries: a systematic review
Introduction
Many low- and lower-middle-income countries (LLMICs) are predisposed to airborne diseases due to inadequate resources and poor health systems.16 Death and social suffering increase with the different types of airborne infection. Globally, tuberculosis (TB), an infection transmitted by airborne droplets, is the leading infectious disease killer of adults. Additionally, the 2019 coronavirus outbreak (COVID-19), another partially airborne respiratory illness caused by SARS Covid-2, has tested healthcare systems' resiliency. Congregate settings (e.g., health care facilities) are an important site of airborne infections transmission among patients and healthcare workers.6
Air disinfection can be highly effective in controlling the spread of airborne infections in congregate settings.25 Ideally, it facilitates high air changes per hour or inactivates airborne pathogens in a room by diluting air through natural or artificial ventilation, filtering air by highly effective particulate air (HEPA) filters, or by using Ultraviolet Germicidal Irradiation (UVGI)— termed as Germicidal Ultraviolet (GUV).8,12, 22 Air disinfection technologies have been effective in controlling nosocomial tuberculosis, measles, and the spread of influenza.22,26 They are currently applied to control SARS-COVID-2 transmission in congregate settings.
Of the various disease control measures, air disinfection through natural ventilation is the principal approach to limiting indoor transmission of airborne infections and has several advantages and limitations compared to other strategies.8,10 The major advantages of natural ventilation are availability, low cost, and high effectiveness under optimal conditions.10 Effective natural ventilation require a proper building design (ideally with large windows and cross-
34 ventilation to encourage air movement), the cooperation of occupants to keep windows open (even when outside conditions are too cool for comfort), and outside climatic conditions that permit open windows and encourage airflow (comfortable temperatures and a breeze). 8,10 Even when all of these conditions are in place, windows are often closed at night for reasons relating to security, superstitions, or due to cold temperatures or rain. Some buildings are not well-designed for natural ventilation. For example, many outpatient clinics have examination rooms with windows on both sides of an internal corridor that also serves as a waiting area. However, when the examination room's doors are closed—as they are most of the time—the waiting areas become unventilated.
When natural ventilation is inadequate, other air disinfection technologies are used if resources permit. Artificial ventilation by HEPA filters is commonly used, especially in a sterile environment such as operating theaters. GUV, like artificial ventilation, also disinfect air independent of air exchange between the internal and external environment, making it widely applicable.
Properly administered air disinfection technologies could significantly reduce the spread of airborne infection in institutional settings such as health care facilities in LLMICs. For example, delayed diagnosis, inadequate treatment of multidrug-resistant (MDR) TB, and exposure to infected people are sources of TB transmission in health facilities.15 MDR-TB has higher mortality and a longer treatment regimen, requiring more financial resources. Like MDR
TB, communicable disease's burden on the healthcare system's resources and human suffering is staggering62,64–justifying efforts to reduce institutional transmission.
Currently, the efficacy of air disinfection technology in preventing nosocomial infection is undisputed, yet available literature does not state the extent of research in LLMICs compared to other regions. A systematic review of air disinfection technology scholarship will serve as the basis for appropriate recommendations and action.
35
Methods
We conducted a systematic review of the literature on air disinfection technology using the PRISMA checklist and pre-established criteria (figure-3). All study types, outcome measures, and subjects were included once the study was conducted in a health facility. All studies conducted outside of a health care facility and in operation theaters were excluded from the review. Operation theatres are limited to technologies that prevent air exchange between the external and internal environment. Since natural ventilation requires internal and external air exchange, it cannot be implemented in an operation theatre.
Studies conducted in a laboratory, a test chamber, or other non-health settings and studies of standalone portable air filters were excluded from the systematic review because they did not test the application of the technology in our desire setting— health facilities. Similarly, we excluded studies conducted in laboratories, test chambers, and standalone portable air filters.
Generally, our outcome measures were the successful (published) research of air disinfection technology in a health care settings. We defined success as a complete study irrespective of an increase in ACH or reduced microbial population. Although studies of GUV artificial ventilation report a reduction in microbial population or decreased transmission of infection after applying the technology, these were not inclusion criteria in our systematic review.
MeSH subject heading and free text were used to search for articles from Pubmed published between 2000-2020, having the keywords—Germicidal ultraviolet, natural ventilation, and artificial ventilation in the title or abstract. Although the search terms and keywords were
English, language was not an exclusion criterion.
36
After obtaining search results from Pubmed, we removed duplicates and screened titles and abstracts for eligibility of full-text review. The full text was reviewed and read in-depth to identify studies that fit the final review's eligibility criteria. The final studies accepted to the review were studies of natural or artificial ventilation and germicidal-UV conducted between
2000-2020 in a health facility. A single author (HS) extracted articles according to a standard procedure (figure 3) developed before the review and adhered to for the entire study.
The final studies were heterogeneous, making it impossible to conduct a meta-analysis.
Alternatively, a narrative synthesis of the results, comparing the numbers of air disinfection studies conducted in LLMICs with those in other regions, is presented to understand the disparity in research between the various areas. The frequent use of a specific form of air disinfection technology and the results (air sample, disease occurrence, etc.) were also compared between the various studies and reported as sub findings from the literature review. Data segregation further presented the frequency of research of a particular air disinfection technology in one region than others and a comparison of the study measures.
Throughout data extraction and analysis, we emphasize adherence to established procedures and rigor in the study. Although there was no need for an IRB, our review was standardized and followed the PRISMA checklist.
37
Figure 3: Search strategy
Results
A total of 11,612 citations were extracted from PubMed after conducting the initial search (Figure-2), of which 182 duplicates were removed, and 11,430 were unique and assessed for eligibility. Following titles review, 11,328 articles were removed for one of the following reasons: title indicated that the research did not include one of the three air disinfection technology in the review, testing other forms of air disinfection technology, addressing water purification, and focusing on the application of disinfection technology to other environmental
38 aspects excluding air. A total of 102 studies were included for further scanning, after which 94 were removed for at least one of the following reasons: conducted in laboratory settings or test chambers, conducted in other locations outside of a health setting, involving standalone air filters, involving mold concentrations, and testing the efficacy of air disinfection — ultraviolet irradiation in various conditions. Of the eight remaining articles, three were removed because they were conducted in Operating Rooms (OR) — a special environment limited to artificial ventilation and GUV, but natural ventilation is inapplicable. This led to a total of five articles for the final analysis.
The systematic review indicated in Table-1 includes five total articles— three (60%) were conducted in high-income countries and two (40%) in upper-middle-income countries. Of the three studies conducted in high-income countries, two (40%) were conducted in the United
States of America and tested UV-C application. The other was conducted in China on the application of natural ventilation. Of the two studies conducted in upper-middle-income countries, one (20%) was conducted in Peru on natural ventilation. The other (20%) conducted in
South Africa tested the application of UV-C.
We found more studies of GUV and natural ventilation in health settings than other forms of air disinfection technology. Of the three (60%) studies conducted on GUV, one (20%) tested the efficacy of prevention against disease (tuberculosis) transmission in guinea pigs, while the other two (40%) tested fungal and bacteria concentration in air treated with GUV. In addition, three (60%) studies tested the application of UV-C in health care settings under different conditions. In comparison, the remaining two (40%) tested the application of natural ventilation also under other conditions. Although data collection and output vary across the various studies, all were designed as experimental studies. Of the five final studies, one measured the occurrence
39 of airborne disease (TB) in exposed subjects (Guinea pigs), one measured air change per hour
(ACH) in naturally versus artificially ventilated health facilities, one measured the rates, determinants, and effects of natural ventilation in health facilities and two measured the efficacy of UV-C in reducing airborne pathogens (bacterial and fungal) in health facilities.
Three (60%) studies testing GUV in health facilities reported the inactivation of bacterial and fungi in the air. In addition, one (20%) study reported the reduction in health-associated infections (HAI) following the application of GUV, and two (40%) studies checked the air change per hour (ACH) in naturally ventilated health facilities.
Air sampling was the common experimental technique used in 3 (60%) of the five studies. Both studies conducted in the US reported air samples before and after implementing
UV in a health setting. The research conducted in Peru reported air samples in several health facilities. One study conducted in China reported the rate of ventilation, and the study conducted in South Africa reported the occurrence of disease in exposed guinea pigs.
40
Table 1: Final studies included in the systematic review
Author (s)/ Date Study area Type of study Study design Outcome of interest Result of study/Statistics reported Effect size Study
Ethington, 2018 USA/ Experimental Reviewing air sample data To verify whether After UV-C installation, airborne 71 bacteria (colony forming units Tina. et al. May special care unit Study (Air for 12 months before and removing bacteria from 42% reduction (SCU) of a sampling) after UV-C installation to the air with ultraviolet [CFU] per cubic meter of air) in infection inpatient rooms were reduced an long-term acute determine the germicidal irradiation rate. average of 42% (175 vs. 1 care hospital effectiveness of UV-C. (UV-C) at the room level 102 CFU/m (3)). Common would reduce infection healthcare-associated infections rates. (HAIs) (Clostridium difficile [8 cases annually vs. 1 case, P = .01] and catheter-associated urinary tract infection [20 cases annually vs. 9 cases, P = .012]) were reduced significantly as were overall infections, in a number of cases (average 8.8 per month vs. 3.5, P < .001), and infection rate (average monthly rate 20.3 vs. 8.6, P = .001), despite no reported changes to the amount or type of cleaning done, infection control protocols, or reporting procedures.
Guiumera, 2018 United States of Experimental Measuring airborne fungal To determine the Mean airborne fungal and bacterial 72 colony forming units were 2 Don. et.al May America/ study and bacteria colony potential role of 78% and 62% pharmacy formation in a pharmacy purification technology obtained preinstallation and again decrease in in 6 months. A statistically before and 6 months after that uses a shielded microbial significant decrease of 78% and population. the installation of a UV ultraviolet C light lamp 62% was observed for fungal and lamp. to continuously purify bacterial particles, respectively. the air in decreasing the spread of airborne pathogens.
41
Mphaphlele, 2015 South Africa/ Experimental Experimental Determine how effective The hazard ratio for guinea pigs in 80% GUV Matsie. et. August Provincial study determination of the is upper room germicidal the control chamber converting efficacy 73 their skin test to positive was 4.9 al referral hospital effectiveness of upper air disinfection with air room germicidal mixing is in reducing (95% confidence interval, 2.8-8.6), with efficacy of approximately irradiation by exposing tuberculosis transmission 80%. 3 guinea pigs to treated and under real hospital untreated air from the conditions and define the same six-bed tuberculosis application parameters ward on alternate days responsible as a basis for when upper room proposed new dosing germicidal air disinfection guidelines. was turned on and off throughout the ward.
Qian, Hua. 2010 China/ hospitals Experimental Measuring the air quality To determine the Air The measurements showed that 74 natural ventilation could achieve et.al March in Hong Kong study in a naturally ventilated Change per Hour (ACH) 69 ACH with 4 hospital through sampling. in a naturally ventilated high ventilation rates, especially windows and when both the windows and the hospital and compare its doors opened doors were open in a ward. The efficiency to mechanical highest ventilation rate recorded in ventilation. this study was 69.0 ACH.
5 A. Roderick 2010 Peru/Hospitals Experimental Using/taking air samples To determine the Opening windows and doors Escombe February in Lima study to investigate the rates, ventilation technology provided median ventilation of 28 28 ACH from et.al75 determinants, and effects (natural or mechanical air changes/hour (ACH), more than Natural double that of mechanically of natural ventilation in ventilation) that provides ventilation. ventilated negative-pressure rooms health care settings. greater Air Changes per ventilated at the 12 ACH
Hour (ACH) and is more recommended for high-risk areas, protective against and 18 times that with windows
Tuberculosis. and doors closed (p < 0.001). Facilities built more than 50 years ago, characterized by large windows and high ceilings, had greater ventilation than modern
42
naturally ventilated rooms (40 versus 17 ACH; p < 0.001). Even within the lowest quartile of wind speeds, natural ventilation exceeded mechanical (p < 0.001).
43
Figure 4: Systematic review process
11,612 articles from initial search 182 duplicates removed.
11,430 after removing duplicates. 11,328 removed during title review.
94 removed during complete 102 after title review content review.
8 after complete review 3 OR studies removed.
5 accepted for final analysis.
Discussion
Although we found no study of air disinfection technology in health care settings in
LLMICs, research conducted in upper-middle and high-income countries across Asia, Africa,
North and South America, and Europe indicates the universal application of air disinfection technology. For instance, GUV studies conducted in South Africa (Table-1), an upper-middle- income SSA country with enormous financial resources, reaffirms the applicability in Africa, given resource allocation.
The amount of financial resources is not always a modulating factor in the application of air disinfection technology. The application of natural ventilation, for instance, requires infinitesimal financial resources for newly constructed buildings and old-fashioned buildings with large doors and windows that promote ideal air exchange.10 In many LLMICs, using open outdoor spaces as patient waiting areas enhance natural ventilation.8 Contrary to this ubiquitous
44 application, our PubMed search did not find studies on natural ventilation in LLMICs, likely due to limited research in these areas. Judicious spending would frown on diverting resources required for critical health care to research in LLMICs.
Studies of natural ventilation were limited to the high and upper-middle-income countries of China and Peru, respectively. The difference in climatic conditions across the two countries stresses the global application of natural ventilation. China has a generally warm and cold climate, whereas Peru typically has a warm environment. Natural ventilation's efficacy depends on wind, humidity, and human behavior to keep ventilation sources (e.g., windows and doors) open.23 Yet, both studies proved the feasibility of applying natural ventilation across two distinct regions.
Like natural ventilation, our result did not find studies of GUV in LLMICs. However, the
WHO TB guidelines recommend the application of GUV as an effective control for nosocomial
TB,19 a prevalent disease in LLMICs. Although GUV’s studies were not found in LLMICs, as mentioned, the ease of retrofitting GUV into existing structures, coupled with the inexpensive installation and maintenance compared to mechanical ventilation, makes it essential. Our systematic review found studies of GUV conducted in high and upper-middle-income countries— the United States of America and South Africa, respectively. This application across two different continents—America and Africa—reveals that the disparity between LLMICs and other regions in GUV research is not due to climatic conditions. Most parts of the United States of America have snowing winter than South Africa's, where winter temperature is relatively mild. Yet, GUV is effective across these two distinct regions.
45
Strength and limitations
Variations in variables, findings, and results between studies made them incomparable.
This discordance in design between the final studies made it impossible to conduct a meta- analysis. For example, some studies measured bacterial and fungal concentration, while others measured disease in the population. Nevertheless, our systematic review rigorously followed an established framework that broadly identified and pulled every available piece of literature from
PubMed (extracted 11,612 articles) published during a period when most modern air disinfection technology research was either conducted or repeated.
Conclusion
The result of this systematic review informs LLMICs of the need to further invest in and publish air disinfection studies in health care facilities, where there is a greater need for these technologies. One might attribute the current disparity in published studies between LLMICs and upper-middle- and high-income countries to the inadequate allocation of resources to conduct research. Investing in air disinfection research is a significant step in improving the application and preventing the spread of common airborne diseases to which LLMICs are susceptible. Safe infrastructure is as critical as safe work and essential in improving health care. Hence, integrating air disinfection technology into new and existing structures is needed. New facilities could implement natural ventilation or GUV, whereas existing facilities could implement GUV at little additional cost.
Our results reveal the paucity in published air disinfection research in LLMICs, despite the overwhelming evidence of its benefits and application in high and upper-middle-income countries.
46
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Appendix
PRISMA Checklist
Reported Section/topic # Checklist item on page # TITLE Title 1 Identify the report as a systematic review, meta-analysis, or both. X
ABSTRACT Structured 2 Provide a structured summary including, as applicable: background; summary objectives; data sources; study eligibility criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and implications of key findings; systematic review registration number. INTRODUCTION Rationale 3 Describe the rationale for the review in the context of what is already X known. Objectives 4 Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design X (PICOS). METHODS Protocol and 5 Indicate if a review protocol exists, if and where it can be accessed (e.g., registration Web address), and, if available, provide registration information including registration number. Eligibility 6 Specify study characteristics (e.g., PICOS, length of follow-up) and report criteria characteristics (e.g., years considered, language, publication status) used as X criteria for eligibility, giving rationale. Information 7 Describe all information sources (e.g., databases with dates of coverage, sources contact with study authors to identify additional studies) in the search and X date last searched. Search 8 Present full electronic search strategy for at least one database, including X any limits used, such that it could be repeated. Study selection 9 State the process for selecting studies (i.e., screening, eligibility, included in X systematic review, and, if applicable, included in the meta-analysis). Data collection 10 Describe method of data extraction from reports (e.g., piloted forms, process independently, in duplicate) and any processes for obtaining and confirming X data from investigators. Data items 11 List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made. X Risk of bias in 12 Describe methods used for assessing risk of bias of individual studies individual (including specification of whether this was done at the study or outcome X studies level), and how this information is to be used in any data synthesis. Summary 13 State the principal summary measures (e.g., risk ratio, difference in means). X measures Synthesis of 14 Describe the methods of handling data and combining results of studies, if results done, including measures of consistency (e.g., I2) for each meta-analysis. X
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