Infection control considerations during construction activities: Land excavation and demolition

Infection control considerations during construction activities: Land excavation and demolition Siu Mee Cheng, MHSc" Andrew J. Streifel, MPH b Toronto, Ontario, Canada

Because current trends in hospital restructuring in North America, amalgamations and mergers, and the aging of health care facilities, the need to restructure physical buildings has become greater. Hospital construction carries with it risks to patients. One key concern is the risk of aspergillosis associated with hospital construction. Infection control practitioners must consider some key factors when addressing land excavation and building demolition, which differ in some ways from construction that occurs within a health care facility. The key factors to consider are project concept, risk assessment of patients, procedures and environment, air quality, routes of entry and egress, soil management, conducting inspections, contingency planning, housekeeping, and lines of cooperation and communication with various stakeholders. Considering these areas will help ensure that health care facility personnel and the workers have exercised diligence in patient care. (Am J Infect Control 2001;29:321-8) Because of the c u r r e n t t r e n d in N o r t h A m e r i c a to restructure hospitals through amalgamations and mergers, a n d with the aging of existing hospital buildings, the need for physical b u i l d i n g redesign has b e c o m e m o r e c o m m o n . M a n y hospitals are experiencing m a j o r c o n s t r u c t i o n activities, including renovation, new development, land demolition, a n d excavation. Several c o n c e r n s exist with respect to controlling the level of dust g e n e r a t e d during these types of construction activity. N o s o c o m i a l outbreaks, p a r t i c u l a r l y outb r e a k s of n o s o c o m i a l invasive aspergillosis, have been a s s o c i a t e d with dust g e n e r a t i o n d u r i n g c o n s t r u c t i o n a n d renovation activities, t-2S Aspergillosis is a disease c a u s e d by the Aspergillus species. This m o l d is ubiquitous in the e n v i r o n m e n t and can be found in a l m o s t a n y building structure with dust. It can cause severe d i s e a s e a m o n g certain p o p u l a t i o n s , 2~29 p a r t i c u l a r l y among persons who are immunocompromised. Patients u n d e r g o i n g bone m a r r o w transplants, patients with leukemia, a n d patients with renal p r o b l e m s have been k n o w n to b e c o m e infected with Aspergillus. W h e n such patients inhale this mold, it has the c a p a b i l i t y of

From the Infection Prevention and Control Unit, University Health Network, Toronto, Ontario, Canada,a and the Department of Environment Health and Safety, University of Minnesota. b Reprint requests: Siu Mee Cheng, MHSc, Infection Prevention and Control Unit, University Health Network, 585 University Ave, 13 NU-118, Toronto Ontario, Canada, M5G 2C4. Copyright © 2001 by the Association for Professionals in Infection Control and Epidemiology, Inc. 0196-6553/2001 $35.00 + 0 17/52/118410 doi: 10.1067/mic.2001.118410

multiplying in and destroying h u m a n tissue (eg, in the heart, kidney, or liver). The severity of the disease is d e p e n d e n t on the patient's i m m u n e system. In patients who are critically ill, a c q u i r i n g aspergillosis is associated with a fatality rate that can be as high as 100%. 3o Other p a t h o g e n s that have been i m p l i c a t e d in nosocomial o u t b r e a k s a s s o c i a t e d with c o n s t r u c t i o n activities include Legionella species, 2' 26 Candida species, 5 Mucor species, ~ Cryptococcus species, 5 Zygomycetes species, 9.19 Rhizopus species, 9 Scedosporium prolificans, 16a n d Sporothrix cyanescens. 'v In all of the recorded cases, hospital c o n s t r u c t i o n a n d susceptibility of the patients are key features. Seasonality, cyclical patterns, humidity, t e m p e r a t u r e , a n d o t h e r e n v i r o n m e n t a l conditions that could act as possible c o n f o u n d e r s have not been f o u n d consistently or identified as factors in the cases. We have also found this to be true in o u r own experiences within o u r organization. As r e s t r u c t u r i n g is taking place, hospitals are seeing a change in p a t i e n t d e m o g r a p h i c s . Patients are generally sicker a n d m o r e i m m u n o c r o m p r o m i s e d t h a n in the past, w h i c h can increase the incidence of n o s o c o m i a l infections related to hospital construction. Moreover, litigation concerns are b e c o m i n g a reality in N o r t h America. A hospital in M a s s a c h u s e t t s was the target of a lawsuit involving the d e v e l o p m e n t of a n o s o c o m i a l fungal infection resulting from dust exposure d u r i n g construction. Claims were also b r o u g h t against the infection control p r a c t i t i o n e r a n d infection control c o m m i t t e e for not e n s u r i n g o p t i m a l patient safety. 31 Infection control p r o f e s s i o n a l s (ICPs) a n d o t h e r health care p r a c t i t i o n e r s m u s t play a greater role during the c o n s t r u c t i o n of health care facilities. Literature exists a d d r e s s i n g c o n s t r u c t i o n activity within hospi-

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tals 32-33, however, literature outlining infection control issues specific to building demolition and land excavation activities that occur near a health care facility and that may pose a health risk to susceptible patients is scarce. Construction activity occurring outside of a health care facility poses a different set of problems than does construction activity occurring within a hospital. This article will outline the steps that should be taken by the ICP or other health care professionals before, during, and after engaging in land demolition or excavation. The following recommendations require risk assessment activities, implementing dust containment and prevention strategies, and ensuring communication and cooperation with stakeholders.

RISK ASSESSMENT A risk assessment is required to help determine the degree of risk to patients from the construction.

Project Concept The ICP will need to determine how the proposed land demolition or land excavation will be conducted; for example, will the building or buildings in question be demolished via explosion, implosion, or by wrecking ball? Because it is associated with lower dust generation compared with implosion and explosion, demolition with wrecking ball is always recommended.

Patient populations The ICP must determine whether the patients being housed in the building that may be affected by external land excavation or building demolition are considered high risk. Patients at high risk include those who are undergoing chemotherapy, a transplant, dialysis, or surgery (eg, same-day admit, main operating rooms, and labor and delivery), as well as patients who are in the intensive care unit, who have cancer, or who are immunosuppressed. The need for appropriate dust containment precautions is great for these patient populations. More details can be found in the APIC Construction and Renovation Tool Kit 33 or the Health Canada Guidelines? °

Patient Procedures The different types of patient care activities that occur within a building located near land demolition or excavation must be considered. This consideration will aid in determining the possible routes of exposure for patients, including inhalation, innoculation, or fomites. Although inhalation is the most common route of exposure for Aspergillus, nosocomial infections have occurred as a result of using contaminated fomites or spores settling on wounds. 3°,34'3sUse of the basic principles of the Spaulding classification system 36 may help

October 2001

identify the likelihood of exposure through routes other than inhalation. Procedures that require entering critical or semicritical sites pose greater risk to patients than procedures that require entering noncritical sites. Patient care procedures that involve entering sterile tissue, contact with mucous membrane, or contact with skin that is not intact need to be identified. Patient care procedures that involve only physical examinations or noninvasive diagnostic procedures are situations in which contaminated dust is less likely to enter into the human body by open wounds or contaminated fomites. Patient care procedures that are located within the same building or wing as administrative offices need to be identified. Although the main occupants may be office workers, who are considered at very low risk of developing construction-related infections, a concern exists for patients located in the same area.

Physical environment The location of the demolition or land excavation and its proximity to nearby occupied health care facilities must be determined. This assessment should include the identification of the types of patient care or support services located near the construction. If the construction is located near high-traffic patient areas (eg, emergency room entrances or outpatient clinics), the need to redirect traffic may be considered. If the project is near shipping and receiving areas, appropriate barriers and prevention measures (eg, timing work around shipping and receiving schedules or relocating receiving docks away from work) must be implemented. These precautions will help protect clean and sterile medical and surgical supplies, linens, and other items that enter the health care facility. It is important to identify where air intakes, windows, doors, fire exits, and utility connections are located and their proximity to the projects.

Air quality In addition to surveying the patient population and patient procedures, other factors that may affect the air quality of the health care facility building must be considered. Air intakes. If the air intakes are located near the site of land excavation or demolition, a possibility exists that air contaminated with dust particulates may be drawn in by the air-handling system. Furthermore, one must consider whether the air-handling system is a recirculated or fresh-air system. For the purposes of land excavation and building demolition, recirculation systems are better than a fresh air system, which will draw all of its air supply from outside the building, rather than "recycling" a portion of used hospital air. Although recirculation systems may draw a percentage of fresh air, the majority of the air that is supplied to the building will be recycled exhaust air. Appropriate

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filters must be in place to lower the contaminants in the recirculated air. Filter systems. Filtration systems in air handling systems must be investigated. Determining what filters exist in the system, which may include a prefilter, a final filter after fan, or a filter at point of air supply grills, is necessary. Generally, prefilters have lower efficiencies than final filters. When considering filter efficiency, consider the proportion of total particulates that it filters from incoming outside air and the size of the particulates it can remove. Tablel provides a summary of international and national recommendations for a facility housing a surge W suite. These parameters help determine what controls, if any, will be needed. If a filter is not in place after the fan, the system may need to be refitted to make provisions for such a filter. The ideal design is to have filters located before and after the fan and at the end of duct systems at discharge supply grills. Frequency of filter change must be determined, which requires the implementation of indicators to monitor filter change. One possible indicator is that of pressure change before and after the filters. As particulates are deposited on filters, the pressure differential will increase. Once the pressure differential reaches a predetermined maximum level (assigned by a facility's building maintenance department), filters should be changed. It is recommended that filters be changed before land excavation or demolition occurs to reduce disruption. Schedules should be determined for changing filters on a frequent and regular basis for the duration of dust-generating activities. Air pressure, Most modern buildings have been built to ensure that the building is under positive pressure relative to the outside environment. However, this must be confirmed during building maintenance. Also, if an elevator shaft is located in the entrance or lobby of the building affected, the air pressure along the elevator shaft system should be determined. Air pressure changes as the elevator cars move up and down the elevator shaft; if the system is under negative pressure, air from the lobby and corridors along the floor will have a tendency to rush into the shaft. In this scenario, the ICP should confirm if the elevator shaft has a dedicated exhaust to determine if contaminated air will be sent directly out to the atmosphere. When pressure in the shaft becomes positive, air can be pushed out onto the floors along the building; thus, the ICP needs to ensure that the lobby or entrance of the building experiences minimal dust entrainment from the exterior. Windows, doors, and other entrances. Windows should always remain closed and should be rendered inoperable within health care facilities. If the windows permit the entrainment of air from the exterior, covering

323

Andersen Samplers Simulates Human Respiratory System Stage 1:=>7 um

Stage

4.7-7

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f~/'-~'~ ~. t~g f __~

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Fig 1. Andersen Air Sampler Stages and the Human Respiratory System? 9 Each stage represents a plate and captures a specific range of particle sizes. The design of the sampler was intended to simulate the natural filtering of the human respiratory system. Stage 1, >7 ~tm;stage 2, >4.7-7 gm; stage 3, >3.3-4.7 gm; stage 4, >2.1-3.3 pm; stage 5, >1.1-2.1 ~tm ; stage 6, >0.85-1.1 ~tm. (Reprinted with permission from Andersen Sampling Instruments, Smyrna, Ga).

windows with an impervious material and sealing them along the seams to prevent dust from entering should be considered. Alternately, windows may need to be resealed. It is extremely important to identify all ports of entry in which dust may enter health care facilities. Fire escape routes and exits, receiving and loading docks, and patient entrances must be identified and an inventory created. If construction occurs near or in front of an entrance or exit, every effort must be made to limit use of the doors (while still observing fire safety codes). Worker traffic should be strictly controlled. Health care workers should be discouraged from using such exits during break times. Stairwells allow for outside air contaminants to travel to patient floors. Controlling dust entrainment through doors may prove more difficult compared with windows. Opening, closing, and moving through doors creates air turbulence that may act against the positive pressure that is normally seen in a building, causing air to rush in as movement occurs. Automatically revolving doors constantly push in air from the exterior to the interior environment. Redirecting traffic away from entrances that face the land excavation or building demolition to another entrance far from the activity would be ideal, but may not always be feasible. Enclosing the entrance away from the dust generation activity so the mouth of the enclosure faces away from the activity is an option.

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Table 1. Summary of international and national r e c o m m e n d a t i o n s for a facility housing a surgical suite Standards/guidelines agency

Filter types

Location of filters

Canadian Standards Association (CSA) 37

30% Prefilter, 95% final

American Society of Heating, Refrigerating and Air-conditioning Engineers (ASHRAE) 38.39

General OR: 25% prefilter, 90% final; OR for orthopedic, organ, and bone marrow transplant: 25% prefilter, 99.97% for 0.3 m diameter, final filter (HEPA) 30% Prefilter, 90% final

American Society of Professionals in Infection Control and Epidemiology (APIC) 36 American Institute of Architects (AIA) 4°

30% Prefilter, 90% final

Prefilter located before the heating/ cooling coils; final filter located near discharge into local areas Prefilter to be located preceding the heating/cooling coils; final filter located near discharge into local areas Prefilter located before the fan and final filter after the fan Prefilter located before the fan and final filter located after the fan

HEPA, high-efficiency particulate air; OR, operating room.

Another possible solution may be to create an air curtain at the inside of the entrance door that pushes air down from the top, forcing air down as it enters through the door and ensuring that it is under positive pressure relative to the outside. Wind direction

Ascertaining usual wind direction may help identify the likely direction that debris will be blown. It is recommended that adjacent outdoor patios and similar seating areas be closed until the construction activity has stopped. Patients, staff, visitors, and particularly inpatients, should be deterred from sitting near construction activity. P R E V E N T I O N AND C O N T R O L STRATEGIES

Once an initial assessment has been made, the ICP or health care practitioner will need to evaluate and weigh the risk to patients. Monitoring activities and prevention and control strategies should be developed on the basis of the evaluation. Monitoring

It is strongly recommended that baseline air samples of total spores and Aspergillus spores be collected for high-risk patient care areas that may be affected by land excavation or building demolition. Air samples provide a picture of endemic levels of total spores and Aspergillus spores for a given patient care area. They also provide a baseline for comparison when sampling is performed during dust-generating activities. Sampler. The Andersen Six Stage Sampler should be used to collect fungal spores. This air sampler is a multiorifice, cascade impactor that is normally used to measure the concentration and particle size distribution of aerobic bacteria and fungi in the ambient air. The sampler contains 400 "jets" (holes) on each of the 6 plates. Each of the plates permit certain micron-sized

particles to pass through. Each plate is meant to simulate each component of the h u m a n respiratory system (Fig 1). Collection media. Once the appropriate sampler is chosen, Inhibitory Mould Agar Plates impregnated with chloremphenicol as recommended by Streife142 should be used as a sampling medium. The plates should be at room temperature before they are used. Andersen does not recommend using regular plastic laboratory petri dishes because any static charge generated reduces the collection efficiency. 4] Andersen's glass dishes should be used instead. Sampling method. The principles and air sampling techniques from the field of occupational and environmental hygiene should be applied to biologic sampling. When sampling for baseline levels, it is important to choose a day that is representative of a typical day at the particular patient care unit. All hospital activities that could possibly interfere with sample collection, such as local maintenance work, local construction activity, or unusually high housekeeping activity, should be identified. Control samples should be taken outdoors and compared with indoor samples. If indoor and outdoor levels differ by a log or more, further investigation is warranted. 43 Outdoor levels should be determined near the area where construction activity is expected to take place and near air intakes and other places where activity may have an impact on occupied areas (eg, near doors and entrances). Andersen Instrumental Incorporate 4~ and Streife143 recommend that sampling take no more than 30 minutes at any one collection time. Andersen has stated that taking a sample for longer than 30 minutes will dehydrate agar plates and perhaps damage the viable particles that have been collected. 42 In addition, if sampling takes place over a long period, difficulty is

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T a b l e 2 . Table of p r o p o s e d spore counts from various sources

Year

198644 19874~ 198943 199646

199442 198747.4s

Source

ACGIH ACGIH ACGIH Reynolds, Streifel, McJilton Streifel Sheretz et all-

Total spore count, outdoors (CFU/m3) -100,000 10,000 100,000

Total spore count, indoors* (CFU/m3) <10,000 --<500

Total spore count, filtered air (CFU/m3)

Aspergillus

Aspergillus,

BMT

spore counts (CFU/m3)

filtered air* (CFU/m3)

Aspergillus

--99 --

spore count (CFU/m3) m

L

15

<0.1 0.009

ACGIH, American Conference on Government Industrial Hygienists; BMT, bone marrow transplant. * Ninety-five percent filter efficiency, 10 air changes per hour. I-Infection rate is 0% in BMT units.

encountered in counting agar plates, especially when more than 250 to 300 colonies exist. The number of colony-forming units collected from just 1 air sample for 30 minutes may not be considered an accurate representation of air quality. It is recommended that various 30-minute samples be collected throughout the day. One agar plate should be left undisturbed as a control and sent to the laboratory to ensure that no plate contamination has occurred. Samples also should be taken from areas not affected by construction or adjacent to the construction as controls; this will help to indicate the presence of other possible contributing factors. When sampling, the air sampler should be placed in the breathing zone area, not on the floor. When sampling in a patient care unit, the sampler should be elevated to a height that is representative of a typical patient's breathing zone. Request that the laborato~ perform colony-forming unit counts for total spores and Aspergillus spores at each of the stages. All spores should be totaled for each of the samples collected during the day and divided by the total volume of air. The Andersen Sampler should have a flow rate of 28.3 L per minute to ensure optimal sample collection. No national or international standards exist on the acceptable spore count for a health care environment. When deciding on acceptable indoor air quality levels for Aspergillus and other fungal spore counts, it is key to determine the risk of disease incidence associated with the level determined. However, Streifel has recommended that total spore counts be no greater than 15 CFU/m~, with a limit of less than 0.l CFU/m 3 for pathogenic Aspergillus and other pathogenic fungi for health care units, which have a 95% final filter efficiency and 10 air changes per hour (ACH)?-~ Table 2 outlines a list of recommendations regarding spore counts for health care facilities. This list is intended for reference use only and not as recommended acceptable counts. We advise using caution when interpreting the table provided and obtaining references for greater detail.

When comparing preconstruction airborne spore levels with levels during construction, one may need to consider whether differences between the 2 levels should be differentiated with rigorous statistical standards (eg, P < .05 level). One may use less rigorous statistical standards to compare the 2 levels when attempting to determine if levels have increased to levels of clinical significance. To deal with high-risk patient populations, one should always err on the side of caution. Sampling frequency. The frequency of samples taken should be considered. Frequency depends on several variables, including the type of construction activity, the susceptibility of patients who may be affected and the duration of the construction activity. Increased sampling frequency should be followed when patients are more at-risk or if the construction activity will generate much dust. The key to sampling is to ensure that samples represent a typical day within the health care facility, while at the same time corresponding with construction activities. Each sampling day should be at least 8 hours, or the duration of a construction workday. As a minimum, sampling schedules should ensure that air monitoring samples are taken before the start of the construction, during construction, and after construction has ended. Sampling frequency requires one to consider the information gathered from the risk assessment, including patient population and procedures, proximity, and degree of dust generation. Once the information is analyzed, sampling frequency should be greater as the risk to patients increases. PREVENTION Inspection

AND

CONTROL

of the worksite

Daily inspections should be made, particularly at the start of a project. Recording inspections and observations is recommended. The inspection should look at major areas, including the following:

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• Dust containment barriers at the source are appropriate. • The frequency in wetting excavated soil or demolished building, truck, and equipment path is adequate. • Doors, windows, and other ports of entry located near the project are sealed or barred from use. • Construction worker behavior, such as removing dust and observing good hygiene before entering into health care grounds, is acceptable. • Waste is kept to a minimum. We recommend that an inspection worksheet be created, with daily inspections and observations recorded and copies given to requisite people who can correct the situation when necessary. The worksheet should include key precautions to observe and a follow-up segment. These worksheets act as a means of communication, and should a problem arise, they become evidence that due diligence was exercised by ICPs and other health care practitioners. Soil m a n a g e m e n t . It is recommended that for land excavation, the soil be moistened or watered down daily. Before considering this control strategy, it should be noted that the moisture may create an ideal environment for Legionella and Aspergillus and other fungal spores. During demolition, the rubble and debris should be watered down. The frequency of watering depends on many factors, such as weather (eg, whether it is sunny or windy), the size of project, and the proximity of the health care facility to the activity. Soil and debris should be removed according to a regular schedule. Contingency plans Contingency plans must be developed to address accidents that may result in increased dust levels being entrained or leakage of contaminated water into occupied hospital buildings. In the plan, procedures must address the following topics: dust containment for highrisk patient care or support areas, patient and health care worker safety, water flooding, and security of medical and surgical instruments and equipment. The plans should identify who has the right to stop work and should describe the communication lines among key services and stakeholders who must be informed if a problem occurs (eg, health and safety, infection prevention and control, facilities management, planning, construction, contractors and subcontractors, and management). Housekeeping It is recommended that housekeeping activities be increased during the construction activity; a greater focus should be placed on removal of dust and cleaning air supply and exhaust grills. Schedules should be created to ensure a more frequent and regular cleaning of

October 2001 common lobbies that may be adjacent to land excavation or building demolition. It is important to identify who has responsibility for cleaning these areas (ie, contractors, housekeeping, or both). COMMUNICATION AND PARTNERSHIPS The infection control program to address construction requires strong communication lines and partnerships to ensure that ICPs and health care practitioners have a proactive role in health care facility construction rather than a reactive role. Facilities management The facilities management department is a strong ally. Members of this department are very familiar with the health care facility and can provide information on the air-handling system. In addition, they are often familiar with the various renovation or construction projects occurring within the health care facility. They can provide ICPs with information about how the occupied buildings operate and possible changes to the operation to accommodate or control dust entrainment into the buildings in question. Contractors Obtaining the cooperation of contractors is key to ensure that the hired work crew observe appropriate behavior when entering a hospital site. Provision of training and education by ICPs and health care practitioners to contractors and subcontractors is the first step in creating a stronger sense of partnership. Training should include information on hygiene, traffic patterns, availability of protective wear (eg, booties and cover gowns), and other dust containment recommendations. Tendering documents should include all expected necessary containment recommendations. These recommendations may include that dust on clothing and boots be removed before entering the health care facility; that entrance to high-risk patient and staff traffic areas be avoided; that cover gowns and booties be made available for workers; and that workers be provided with portable toilets for their use only with potable water to wash, preferably outside of occupied health care facility grounds. These precautions will help limit the amount of dust being introduced into the health care facility. A partnership with contractors will help ensure greater respect for infection control concerns among construction workers and raise the level of ICP awareness regarding the different phases of the project, particularly high dust-generating activities (eg, demolition of a targeted building). Clinical departments and health care workers Clinical patient care services that may be affected by the construction should be apprised of the work sched-

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ule. I C P s s h o u l d p r o v i d e t r a i n i n g a n d r e c o m m e n d a t i o n s t o p a t i e n t c a r e f l o o r s t h a t will a s s i s t in m i n i m i z i n g p a t i e n t e x p o s u r e a n d allay a n y s a f e t y c o n c e r n s o f h e a l t h c a r e w o r k e r s . 3 0 , 3 3 If d u s t levels a r e e l e v a t e d as a r e s u l t o f t h e p r o j e c t , t h e c l i n i c a l s e r v i c e in q u e s t i o n m u s t b e a w a r e o f w h o m to c o n t a c t a n d b e a b l e to p u t in p l a c e t h e n e c e s s a r y p r e v e n t i v e m e a s u r e s . R e c o m mendations

regarding

appropriate

staff behavior

s h o u l d be made. For example, staff s h o u l d avoid use of exits t h a t l e a d to d e m o l i t i o n o r l a n d e x c a v a t i o n sites, s h o u l d a v o i d s t a n d i n g in s u c h a r e a s , a n d s h o u l d k e e p doors closed.

Developers (external hospital development) Lastly, the a f o r e m e n t i o n e d r e c o m m e n d a t i o n s are for both hospital-funded and nonhospital-funded construction activities (eg, c o n d o m i n i u m developers). M e e t i n g w i t h developers, outlining the c o n c e r n s a n d p r e c a u t i o n s , a n d d e t e r m i n i n g a key c o n t a c t are strongly r e c o m m e n d e d .

CONCLUSION T h e role o f ICPs in t h e a r e a s o f c o n s t r u c t i o n , l a n d e x c a v a t i o n , a n d b u i l d i n g d e m o l i t i o n is c o m p r e h e n s i v e a n d vast. The ICPs m u s t b e c a p a b l e o f p e r f o r m i n g several activities. Risk a s s e s s m e n t s m u s t b e c a r r i e d o u t to i d e n t i f y h i g h - r i s k p a t i e n t p o p u l a t i o n s , p a t i e n t c a r e activities, a n d p h y s i c a l p l a n t c o n d i t i o n s . Air s a m p l i n g a n d i n s p e c t i o n s will n e e d to b e c o n d u c t e d to d e t e c t p o t e n t i a l p r o b l e m s . C o n t i n g e n c y p l a n n i n g is n e e d e d to h e l p deal w i t h p r o b l e m s t h a t m a y occur, a n d s t r o n g c o m m u n i c a t i o n lines a n d p a r t n e r s h i p s m u s t b e d e v e l o p e d a m o n g v a r i o u s s t a k e h o l d e r s . It is r e c o m m e n d e d t h a t i n f e c t i o n p r e v e n t i o n a n d c o n t r o l u n i t s c o n s i d e r d e d i c a t i n g at least o n e s t a f f m e m b e r to h a n d l i n g all c o n s t r u c t i o n - r e l a t e d i s s u e s a n d p r o j e c t s . At all t i m e s , d u e d i l i g e n c e m u s t b e e x e r c i s e d b y t h e ICP o n b e h a l f o f t h e i n f e c t i o n c o n t r o l c o m m i t t e e a n d the h e a l t h c a r e facility. We thank Helmut Hupke, Johnson Controls and University Health Network, for providing information and advice on HVAC systems; Wayne Jones, Andersen Instruments Incorporated, for providing information on the Andersen six-stage sampler: Dr Andrea Sass-Kortsak, University of Torunto, for providing advice on air quality sampling plfinciples; and Dr John M. Conly, University Health Network, for acting as a resource on infection control issues related to health care construction.

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