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Our results showed that the UV irradiance varied considerably depending upon the surface location. For example, with the UVGI fixture in the back position and without the addition of UV-reflective surfaces, the most irradiated location received a dose of UVGI sufficient for disinfection in 16 seconds, but the least irradiated location required 15 hours.
Because the overall time required to disinfect all of the interior surfaces is determined by the time required to disinfect the surfaces receiving the lowest irradiation levels, the patient compartment disinfection times for different UVGI configurations ranged from These results indicate that UVGI systems can reduce microbial surface contamination in ambulance compartments, but the systems must be rigorously validated before deployment.
Optimizing the UVGI fixture position and increasing the UV reflectivity of the interior surfaces can substantially improve the performance of a UVGI system and reduce the time required for disinfection.
Ambulance patient compartments are frequently contaminated with pathogenic microorganisms shed by patients during transport.
These microorganisms can potentially be transferred to subsequent patients and to emergency medical service EMS workers by direct contact with the surfaces or by indirect transmission via hands or medical items.
The potential risk for the transmission of infections via contaminated surfaces is of great concern to the EMS community and could become a critical problem during an infectious disease pandemic, when large numbers of highly contagious patients would be transported and when the ability to decontaminate ambulances and return them to service as soon as possible would be needed.
In , the InterAgency Board, a working group of emergency preparedness and response officials, listed the development of rapid decontamination systems for ambulances as one of its research priorities.
Current procedures for infection prevention in emergency medical services typically call for the interior of the patient compartment to be cleaned of visible bodily fluids or soil, sprayed with an approved disinfectant, wiped after the appropriate contact time, and allowed to air dry.
Roline et al. Brown et al. Rago et al. Valdez et al. Standard cleaning practices only partly reduced the contamination.
A study of Ohio EMS personnel found that 4. One potential method to reduce the risk of disease transmission in patient compartments is disinfection through the use of whole-compartment systems, such as disinfectant foggers or ultraviolet germicidal irradiation UVGI.
Such germicidal systems are employed as a final disinfection step after the patient has been removed and visible contamination has been cleaned called terminal disinfection.
Terminal disinfection systems do not eliminate the need to first manually clean heavy or visible contamination. However, the use of a terminal disinfection system could allow the manual cleaning to focus on surfaces that are visibly contaminated or most prone to contamination, rather than attempting to wipe down every surface in the ambulance.
UVGI has been studied as a method for surface disinfection in hospital rooms reviewed by Weber et al. Anderson et al. Jinadatha et al. Nerandzic et al.
Pegues et al. Rock et al. In a recent large multi-hospital clinical trial, Anderson et al. UVGI systems have several potential advantages for terminal disinfection.
They are relatively simple and easy to use, and do not leave chemical residues or risk exposing patients and workers to toxic chemicals.
In ambulances, UVGI systems can be used while the crew cab is occupied, while fogging systems cannot.
However, UVGI systems also have an important limitation: Because most materials are not good reflectors of ultraviolet light at germicidal wavelengths primarily nm , UVGI systems are less effective against microorganisms on surfaces that are not in a direct line-of-sight of the system.
One approach to improving the performance of these systems is to cover surfaces with UV-reflecting materials or coatings in order to better irradiate shadowed areas.
Rutala et al. Jelden et al. Although terminal disinfection systems are increasingly popular for use in patient rooms in hospitals, 8 more information is needed about how well they work and how best to use them.
The Centers for Disease Control and Prevention CDC recommends against the use of disinfectant fogging systems employing formaldehyde, phenol-based agents, or quaternary ammonium compounds in patient-care areas.
Although UVGI systems are being marketed as a means of surface disinfection in ambulances, a search of the biomedical literature located only one study which mentioned that UVGI was used for terminal disinfection of ambulances used for transportation of patients with Ebola virus disease, and in that case no test results or details about the system were provided.
Before UVGI systems can be reliably used in ambulances, much more information is needed about their efficacy and limitations in this application.
The purpose of this project was to test the ability of an ultraviolet germicidal irradiation system to disinfect the interior of an ambulance patient compartment, to examine the variations in irradiance among different locations in the compartment, and to study the effects of the location of the UVGI fixture and the addition of UV-reflective material or UV-reflective paint on the efficacy of the UVGI system.
The information provided by this study will help to better understand the uses and limitations of UVGI systems in ambulances.
The patient cot was removed from the ambulance for all experiments. Ambulance patient compartment showing the locations of the UVGI sensors.
A more detailed color schematic and photographs of the ambulance patient compartment are provided in the on-line supplemental material. The ultraviolet germicidal light fixture used in these experiments was custom-built.
Each lamp had a nominal wattage of 60 watts and a UV wattage of The lamps were mounted vertically in two circles one upper, one lower around an Photographs and a diagram of the fixture are included in the on-line supplemental material.
The light fixture positions are shown in the ambulance patient compartment schematic in the on-line supplemental information.
Irradiance measurements were made at 49 locations throughout the patient compartment as shown in Figure 1. A descriptive list of the locations is given in Table 1 ; photographs and an interactive schematic showing the sensor locations are included in the on-line supplemental material.
The sensor locations were chosen to emphasize two areas: 1 surfaces that are frequently touched such as controls, handles, latches and hand rails, and 2 surfaces that were not directly exposed to light from the UVGI fixture, such as between the primary care seat and the wall, and in the passageway leading to the front cab.
Descriptive list of UVGI sensor locations in the ambulance patient compartment. The locations are shown schematically in Figure 1 and in the on-line supplemental materials.
A scan delay of 3 seconds was used for the switch boxes to prevent measurements from one sensor from being carried over to the next sensor reading.
To perform irradiance measurements, the sensors were placed at 17 locations. The UVGI light fixture was turned on and allowed to stabilize for 30 minutes.
Separate irradiance measurements were collected with the fixture in the back, middle and front positions. The fixture was then turned off and 16 of the sensors were moved to different locations; one sensor was left in the same location B2 for all tests to allow comparison of irradiance levels from different tests.
The measurements were collected using the three light fixture positions. The fixture was turned off, 16 sensors were moved to the final set of locations and the measurements were repeated.
The entire set of measurements was repeated three times with the sensors rotated among the locations, so that measurements were collected three times with different sensors at each location for each UVGI fixture position data points.
To prevent exposure of personnel to UV-C, the exterior of the patient compartment windows were covered with aluminum foil, warning signage was placed on the ambulance doors and access to the ambulance was restricted during experiments.
One person was allowed to enter the ambulance to move the UVGI fixture while it was on; this individual was completely covered in protective clothing and wore a UV-C absorbing face shield.
To examine the effects of surface reflectivity, three different ambulance interior surface conditions were tested. The side panels and ceiling were primarily white melamine with aluminum trim and vinyl-covered padding on the edges.
The cabinet sliding doors were clear plastic, the access doors were largely covered in diamond-plate aluminum, and the floor was a dark grey non-skid plastic material.
Seat cushions were covered with blue vinyl. Diamond-plate aluminum sheets also were added to the floor beneath the rearfacing primary seat and the patient cot release handle.
The positions of the added reflective material are shown in the on-line supplemental material.
The floor, the original aluminum sheets and trim, and the seats and padding were not painted and remained in their original state.
The antimicrobial capabilities of the UVGI system were tested using Bacillus subtilis spores as a surrogate for pathogenic microorganisms.
Since it is not a human pathogen, B. Bacillus subtilis subsp. To determine the dose-response relationship between UV-C and B. After exposure, each coupon was placed in a 6-well culture plate.
Five ml of sterile 0. The UVGI irradiance intensity and spore inactivation data were fitted to an exponential decay model of the form 15 , The UVGI dose required to disinfect a surface was calculated based upon the k-value found in the laboratory exposure experiments.
This surface disinfection dose was divided by the irradiance measurements in the ambulance to calculate the exposure time required to disinfect each location in the compartment the disinfection time with the different fixture positions and surface reflectivities.
The disinfection dose was used to convert irradiance levels to disinfection times when presenting the results because the disinfection time is easier for the reader to interpret.
Irradiance levels for all experiments are provided in the on-line supplemental materials. To test the ability of the UVGI system to inactivate microorganisms in the ambulance, spore-loaded coupons were fastened next to the inlet domes of the ultraviolet light sensors.
Ten coupons were placed in the locations in the ambulance with the lowest irradiance levels for each interior surface type.
Two control coupons were not exposed to UVGI but were otherwise treated in the same manner. The test was performed 6 times with the original interior surfaces, 3 times with the reflective interior surfaces, and 3 times with the UV-reflective paint on the interior surfaces.
For all of these experiments, the UVGI fixture was placed in the back position for first half of the exposure time and in the front position for the second half.
The dose-response curve for Bacillus subtilis spores dried onto stainless steel coupons resulted in a rate constant k of 0. The average temperature in the exposure box during these experiments was Based on these results, a UV-C dose of This disinfection dose was used with the UV-C irradiance levels measured with the radiometers to calculate the disinfection times in the results presented below.
The shortest, median and longest exposure times required for disinfection among the different locations in the ambulance are shown in Table 2 for each UVGI fixture position and interior surface type.
Locations that were further away from the UVGI fixture or in shadowed areas received much lower UV-C doses than did locations closer to the UV fixture and directly in the line-of-sight.
For this reason, the longest disinfection times were to times larger than the shortest times Table 2.
As a practical matter, the longest disinfection time determines the estimated overall time required to disinfect all locations in the interior of the ambulance.
The overall disinfection time ranged from Shortest, median and longest disinfection times among the 49 test locations for each interior surface and UVGI fixture position.
Note that the shortest time is given in seconds, while the other times are given in minutes. The longest disinfection time is the time required to inactivate Figure 2 shows the disinfection times at each of the 49 test locations in the ambulance with the UVGI light in the middle position and with the original interior surfaces.
In this experiment, the disinfection times ranged from 20 seconds at location G6 on the left wall directly facing the UVGI fixture to minutes at location B6 between the rear-facing primary patient care seat and the left wall, facing the wall , indicating that location G6 receives times as much UV-C light as does location B6 with this configuration.
Surface disinfection time exposure time required to inactivate Each bar shows the average of 3 experiments. Error bars show the standard deviation.
The disinfection times when the UVGI fixture was in different positions in the ambulance and with the original interior surfaces are shown in Figure 3.
The locations presented in the figure include the 5 worst locations that is, the locations with the longest disinfection times for each light position.
Note that, as the light is moved to different positions, the disinfection times for some locations improve while others become worse.
For example, when the light was moved from the front to the back, the disinfection time for location B12 vertical hand rail on left rear door decreased from 72 minutes to 7 minutes, while for location W1 bottom step at side door the disinfection time increased from 32 minutes to minutes.
For the original interior surface condition, the worst overall disinfection time of minutes occurred when the UVGI fixture was in the front position in the ambulance, and the best overall disinfection time of minutes occurred when the fixture was in the middle position.
The results for all interior surface conditions are summarized in Table 2. Effect of UVGI light position on the surface disinfection time at different locations.
These experiments were conducted with the original interior surfaces and the UVGI fixture in the front, middle, or back position.
The locations shown were chosen based on the 5 longest disinfection times for each light position. The effects of adding aluminum sheets or UV-reflective paint to the interior surfaces are shown in Figure 4.
The results presented in this figure were calculated assuming that the UVGI fixture was placed in the front, middle and back positions for one-third of the exposure time each.
With the original interior surfaces, the time needed to disinfect all locations was minutes. The overall disinfection time was reduced to 79 minutes by adding the reflective aluminum surfaces, and to 59 minutes by painting the interior with the UV-reflective paint.
Effect of ambulance interior surface treatments on the surface disinfection time. These results were calculated assuming that the UVGI fixture was placed in the front, middle and back positions for one-third of the exposure time each.
As described in the materials and methods section, original refers to the ambulance interior surfaces as they were originally made by the manufacturer.
Reflective refers to the addition of reflective aluminum plating to various interior surfaces as shown in the on-line supplemental material.
UV paint refers to coating the white melamine interior surfaces of the ambulance with white UV-C reflective paint.
The locations shown were chosen based on the 5 longest disinfection times for each interior surface. The survival fraction vs. UVGI dose for Bacillus subtilis spores on coupons placed in the ambulance is shown in Figure 5 , along with the predicted survival curve from the laboratory experiments.
The correlation coefficient between the laboratory model and the ambulance results was 0. After 20 minutes, the survival fraction of the spores in the ambulance ranged from 0.
The average temperature during these experiments was Each coupon of spores was mounted alongside the sensor dome of a radiometer, which was used to measure the UVGI dose received by the coupon.
The solid line is the predicted survival based on the laboratory tests. The dots show the results from coupon tests in the ambulance.
Ultraviolet germicidal irradiation is being marketed as a terminal disinfection method for ambulance patient compartments. UVGI is very effective at inactivating microorganisms if the microbes receive a large enough dose of ultraviolet light.
However, ensuring that all surfaces within the compartment are sufficiently irradiated to disinfect them requires careful planning and testing and an appreciation of the limitations of UVGI systems.
UVGI irradiation levels varied greatly from place to place within the ambulance compartment. As seen in Figure 2 , this caused the disinfection times to vary considerably with surface location as well.
Since the purpose of the UVGI system is to disinfect as much of the patient compartment as is practically possible, the time required for overall disinfection is driven by the locations with the lowest irradiance levels, not by the average irradiance.
For this reason, interventions that increase the irradiance of the worst locations will reduce the overall disinfection times for the ambulance compartment and allow for a more rapid turnaround of the ambulance.
For each combination of UVGI fixture position and surface reflectivity, the median disinfection time among all locations was much less than the longest time Table 2.
In addition, a particular effort should be made to find the locations with the lowest irradiance levels, since these locations will determine the exposure time needed to disinfect the entire compartment.
On the other hand, this also suggests that the overall disinfection time can be lowered substantially by increasing the irradiance of a small number of areas that are most shadowed from the UVGI fixture, or by determining that some areas either do not require disinfection or that those areas will need to be disinfected by other means.
The position of the UVGI fixture had a substantial effect on the overall disinfection time for the compartment. With the original interior surfaces, moving the fixture from the front to the middle position reduced the disinfection time from The ratio of the longest time to the median time was also reduced from to 31, suggesting that the light was more evenly distributed.
Similar results were seen with the reflective material and the UV-reflective paint. An additional step that can be taken to better distribute the UV light within the compartment is to move the UVGI fixture during disinfection.
We examined two possibilities: placing the fixture in the front position for half of the disinfection time and the back position for the other half; and placing the UVGI fixture in the front, middle and back position for one-third of the disinfection time each.
With original interior surfaces, moving the fixture did not improve the disinfection time compared to leaving the fixture in the middle position.
However, with the reflective aluminum, the disinfection time was reduced from minutes with the light in the front position to 81 minutes by splitting the exposure time between the front and back positions.
With the UV-reflective paint, splitting the exposure time between the front and the back reduced the disinfection time from 79 minutes to 67 minutes compared to leaving the fixture in the middle, and splitting the time between the front, middle and back reduced the time to 59 minutes.
Further reductions in the disinfection time could be achieved by using a more powerful UVGI fixture or using multiple fixtures for disinfection; using two fixtures, for example, would potentially cut the overall disinfection time in half.
One way to enhance the efficacy of UVGI fixtures is to increase the UV reflectivity of surfaces in the compartment so that more UV irradiation reaches locations that are not directly exposed.
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