Singing, Covid-19, and the Future of Live Entertainment – Part 2

Singing, Covid-19, and the Future of Live Entertainment – Part 2

Read part 1 of this blog post here.

Since the early days of the covid-19 pandemic, singing has been a super-spreading culprit leading to an effect on the future of live entertainment.

What about Singing?

Until Covid-19 emerged, just one study, conducted in 1968 and prompted by choir-related TB outbreaks, had analyzed particles generated by singing. The study involved just three singers, none of them professionals.

Forty years later, the explosion of choir-related coronavirus outbreaks prompted larger, more robust, and more sophisticated studies. These trials, in combination with prior flu-focused research, provide insight on the safest way to reopen live entertainment and dining venues.

Scientists at Sweden’s Lund University, for example, compared respiratory emissions from 12 vocalists, including seven opera singers, under three conditions: singing, reading a book out loud, and breathing silently.

With metal funnels fitted around their faces, the volunteers performed for 2 minutes at a time while a vacuum pump continually introduced fresh air into the funnel. A high-speed camera imaged the emissions produced by five of the singers.

Overall, the results were unsurprising: “Normal singing generated significantly more aerosol particles than normal talking. Loud singing produced more particles than normal singing.” Also, the professional singers generated about twice as many particles as the amateurs.

One finding, though, was intriguing. While loud singing and loud talking both generated vastly more particles than normal talking and breathing, the difference between both types of loud vocalization was relatively small. In other words, infection might spread as readily at a noisy pub as at musical performance.

University of Bristol scientists obtained similar, but even more dramatic, results when they studied emissions from 25 professional singers from a broad range of genres — gospel, opera, jazz, and pop, among them.

Performing in a highly filtered operating theatre, volunteers sang single notes at different pitches. They also sang and spoke the “Happy Birthday” song at multiple volumes.

Like the Swedish scientists, the UK team found singing generates more aerosol than talking — about 1.5 to 3 times more. These differences, however, were “eclipsed by the effect of volume on aerosol production.”

Both loud singing and loud talking produced an astonishing 20 to 30 times more aerosolized particles than vocalizing at a typical volume.

Why Pubs and Future Live Entertainment Music Venues Must Clean the Air

Loud singing and loud talking — those are the hallmarks, along with exuberant merrymaking. TradFest, Dublin’s annual 5-day celebration of Irish music and culture. Since 2005, the festival has drawn top bands and massive crowds to historic churches, castles, and pubs. It’s an aerosol eruption of the highest order. Yet when the pandemic struck, organiser Martin Harte was determined not to cancel. With the right precautions, he felt, live performances could happen, even if live audiences could not.

Novaerus Defend 1050
Novaerus Defend 1050 at TradFest

At the time, plastic dividers and relentless surface cleaning protocols were all the rage in entertainment and hospitality. “Everyone was obsessed with handwashing and hygiene, as opposed to cleaning air,” Harte recalls. Even today, more than a year into the pandemic, “disinfectant mania” persists while ventilation, filtration, and air dis-infection are undervalued.

“Some people still don’t get it,” asserts microbiologist Emanuel Goldman, Ph.D., of Rutgers New Jersey Medical School. “They’re distracting the public from the measures that can really protect them.”

Among the most protective measures is air dis-infection, particularly NanoStrike technology, used in Novaerus portable devices.

Inside Novaerus’ sleek, compact units, coil tubes produce an electrical discharge that obliterates pathogens at the molecular level. Instantly, the DNA of a virus or bacteria becomes inert, harmless debris, and clean air is released back into the room.

Noaverus technology has been used in over 60 countries to fight Covid-19, particularly in hospital operating rooms, Covid wards, emergency departmentes, waiting rooms, and surgical theatres.

That’s largely why Harte chose Novaerus as his solution for TradFest 2021. For five days, musicians performed at Dublin Castle, with portable Novaerus units parked in the castle’s historic rooms but out of camera range.

“Novaerus isn’t a hygiene product,” says Harte. “This is something you’ll find in an ICU, in a neonatal unit. That was the level of protection we wanted.” The devices featured prominently in TradFest’s safety proposal to the Office of Public Works, the government agency that operates Dublin Castle.

“Novaerus helped us hugely in securing approval to use the castle and made all the difference in getting musicians to agree to perform,” Harte says.

TradFest deployed Novaerus’ most powerful unit, the Defend 1050, which has been cleared by the U.S. Food and Drug Administration as a 510(k) Class II medical device.

 In independent laboratory testing, the Defend 1050 has demonstrated a 99.99% reduction of live SARS-CoV-2 virus, within 30 minutes. Like other Novaerus units, the Defend 1050 shown similar efficacy with other airborne pathogens, including influenza, Clostridium difficile, Aspergillus, and surrogates for Measles virus, tuberculosis, and Methicillin-Resistant Staphylococcus Aureus (MRSA).

NanoStrike technology also destroys surrogates for tuberculosis and measles — two deadly pathogens that, while tamed, were never eradicated and continue to plague the globe, infecting millions each year. That may be the destiny of SARS-CoV-2, a virus expected to circulate well beyond the end of the pandemic.

For this reason, Harte says, and because he knows that noisy conversation itself can generate highly infectious aerosol plumes, he has encouraged bars and restaurants throughout Temple Bar, Dublin’s primary tourist district, to deploy Novaerus devices.

“I don’t think you can safely open any establishment, anywhere, without cleaning the air.”

If you are interested in learning more about the Novaerus products, additional information can be found here, or please contact Novaerus.

Singing, Covid-19, and the Future of Live Entertainment – Part 1

“Particles shoot out like a geyser”: Singing, Covid-19, and the Future of Live Entertainment

Since the early days of the covid-19 pandemic, singing has been a super-spreading culprit leading to an effect on the future of live entertainment.

Around the world, choristers have become infected at remarkably high rates. At a rehearsal in the United States, 53 of 61 singers contracted Covid-19, and a practice in France infected 19 of 27. A choir seminar in Austria left 43 of 44 singers infected, and after the Amsterdam Mixed Choir performed Bach’s St John Passion, 102 of 130 members fell ill.

Karaoke, too, has sparked numerous outbreaks, including an explosion of cases traced to a popular Quebec City bar. In the coronavirus era, noted Quebec City’s health director, “All singing poses a problem.”

Science shows that’s true. Singing emits high volumes of aerosol, and infectious particles generated by one singer can sail across a choir hall, as far as 13 meters, only to be inhaled by another. But is singing more hazardous than, say, loud conversation at a pub? Not substantially.

As British scientists have found, aerosol transmission of disease is “equally possible” whether the particles are produced by singing or loud speaking — a finding of importance to anyone who operates an establishment noisier than a library.

With vaccinations underway, we can plan for a time when choirs reconvene, karaoke bars reopen, restaurants operate at full capacity, and musicians get back on the road. But post-pandemic, the landscape for entertainment and hospitality will look different than it did before.

Moving forward, building operators will need a working knowledge of SARS-CoV-2 transmission and of the precautions, such as air dis-infection, proven to mitigate the risks of singing and socializing indoors.

“Covid is here to stay, in some shape or form, and we need to adapt,” says Martin Harte, CEO of The Temple Bar Company, the not-for-profit organiser of TradFest, Ireland’s largest festival of traditional music. Harte adapted by installing medical-grade air dis-infection devices at Dublin Castle, the historic fortress where TradFest musicians performed indoors, with government permission, amidst the pandemic. The sessions, livestreamed to a global audience, did not lead to a single infection.

“Music travels through the air, and so does the coronavirus,” says Harte. “I wasn’t going to put our performers or crew at risk.”

From TB to Covid: The Super-Spreading Power of Singing

In 1962, at an American boarding school, two boys, feverish and coughing, were diagnosed with tuberculosis and admitted to the hospital. Testing at the school turned up 25 more cases. A medical team was dispatched to study the outbreak. At the time, conventional wisdom held that TB was transmitted via large respiratory droplets and close contact. But intriguing rodent studies suggested otherwise. If guinea pigs could become infected from afar, perhaps humans could, too.

But how? What behaviors might spread the disease?

At first, the medical team was stumped. Though all 153 students slept in a single, poorly ventilated dormitory, the TB cases were randomly distributed. Classroom and chore groupings revealed no patterns, either.

But further analysis yielded a clue: Among members of the school choir, 60% contracted TB, compared to just 20% of the student body as a whole. Reporting in the Journal of the American Medical Association, the doctors noted that three other mid-century TB outbreaks had been associated with choir singing.

“It seems quite possible,” the doctors wrote, “that vigorous singing could be an effective generator of fine particles in large quantity.”

Today, we know that’s not just “possible” — it’s a fact.

“When you sing, microscopic particles burst forth from your mouth in a fountain of mist . . . shooting out like a geyser,” explains James Hamblin, M.D., an American public health physician. “The rush of exhaled air creates an aerosolized mixture of everything that’s lingering in the mucus membrane of your pharynx.”

This location, he notes, is “exactly where the coronavirus attaches and replicates.” Until Covid-19 began rampaging through choirs, the connection between singing and disease transmission had largely been forgotten.

Instead, aerosol scientists focused on more ordinary sources of respiratory emissions — coughing, sneezing, talking, and breathing. Studies were conducted for the purpose of helping reduce spread of the flu.

As one prescient research team, from the U.S. National Institute for Occupational Safety and Health, noted: “To prepare for a possible influenza pandemic, a better understanding of the potential for the airborne transmission of influenza from person to person is needed.”

What that study found: while coughing generated more viable influenza particles than mere breathing, the difference was not large and “both respiratory activities could be important in airborne influenza transmission.”

Another flu-focused study compared emissions while speaking at various volumes. “We showed that as you talk louder, no matter what you say, you will release more particles,” reported chemical engineer Sima Asadi, Ph.D., the study’s lead author.

The key take-away, Asadi said: “Talking is potentially as important as sneezing and coughing for influenza transmission.

Read part 2 of this blog post here.

TradFest Temple Bar 2021

As Covid-19 spread around the world, live music events everywhere were canceled or postponed. TradFest Temple Bar, an annual live music festival celebrating Irish music and culture, reimagined their iconic event with the help of Novaerus air dis-infection technology from WellAir.

A live music festival reimagined for the COVID-19 era.

Every January, Dublin’s famed Temple Bar district erupts with music and joy, as TradFest Temple Bar — a five-day celebration of Irish music and culture — draws top bands and massive crowds to historic churches, castles, pubs, and other iconic venues.

TradFest Temple Bar 2020 beat the Covid-19 pandemic by mere weeks, wrapping up just before live music everywhere came to a screeching halt. When it came time to plan TradFest Temple Bar 2021, the virus was on its second rampage, and prospects for live performances had worsened. Science had established that SARS-CoV-2 was airborne and that singing was especially risky.

Novaerus Protect 800 at Tradfest Temple Bar 2021
Novaerus Protect 800

Worldwide, music festivals were cancelled. But Martin Harte, CEO of The Temple Bar Company, the not-for-profit organiser of TradFest, wasn’t having it. After all, Tradfest, Ireland’s largest festival of traditional music, had run annually since 2005.

“I said, ‘No, the show must go on,’” recalls Harte. And it did. In the throes of the pandemic, TradFest delighted fans with a scarce commodity: music performed live and indoors.

Novaerus Medical-Grade Air Dis-Infection Technology

The audiences weren’t live, of course; the concerts were streamed. But the artists performed within the storied, stone walls of Dublin Castle, a fortress that dates back to 1230 and, just for TradFest 2021, was outfitted with Novaerus medical-grade air dis-infection technology from WellAir. Over five days, some 50 musicians and crew members gathered to rehearse, pose for photos, and perform amidst rococo ceilings and portraits of Irish viceroys — all the while breathing air cleaned by sleek, white Novaerus devices out of camera range.

Novaerus Defend 1050 at TradFest Temple Bar 2021
Novaerus Defend 1050

The devices featured prominently in TradFest’s safety proposal to the Office of Public Works, the government agency that operates Dublin Castle. “The Novaerus devices helped us hugely in securing approval to use the castle,” says Harte.

Of course, it wasn’t just government authorities that needed convincing; the performers and crew — ages 18 to 80, emerging artists and folk legends alike — had to feel protected. “Novaerus devices made the difference in getting people to agree to perform,” Harte says. During the event, artists, and staff noted the quiet presence of Novaerus devices, says Harte. “I pointed out that right on the back of the machine, it says ‘infection control device.’ People felt reassured and relaxed.”

A Covid-Free Event
Novaerus Defend 1050
Novaerus Defend 1050

The technology helped foster a sense of normalcy in decidedly abnormal times. “It was a lovely and very hopeful atmosphere,” says Deirdre Devitt of The McGreals Group, a TradFest sponsor and Novaerus distributor. “You could feel the sheer joy the performers and crew were feeling.”

The festival proved to be entirely Covid-free — “We had no illness, nothing,” reports Harte — while the same could not be said for the rest of Ireland. “During that week, Covid got out of control,” says Harte. “Three days after we finished shooting, Ireland closed down. Dublin Castle was possibly the safest space you could be in the whole country.”

When the pandemic struck, Harte knew nothing of Novaerus devices. He just knew he wanted TradFest 2021 to happen — somehow. “People need culture, and artists need work, and there was the commercial opportunity for us to sell tickets worldwide,” Harte says.

Following the Science
Novaerus Protect 800
Novaerus Protect 800

Harte delved into research on Covid-19 transmission and became convinced, early on, that the disease was largely spread via aerosol. He even read up on tuberculosis, another disease that was initially considered transmissible only via large droplets but was ultimately proven to be spread by microscopic viral particles. Harte noticed, too, that businesses were scrambling to install plastic dividers and disinfect surfaces, disregarding the real threat: infectious aerosols. “I could see we were making the same mistakes with Covid that they made with TB,” Harte recalls.

Harte’s global search for a solution led him back home to Ireland, where WellAir’s Novaerus technology was being developed and manufactured for use in medical settings.

“Novaerus isn’t a hygiene product — it’s something you’ll find in an ICU, in a neonatal unit,” says Harte. “That was the level of care we wanted. Our brand is too strong and our audience and performers are too important to put them at risk.”

Reopening in the COVID-19 Era
Novaerus Protect 200 at TradFest Temple Bar 2021
Novaerus Protect 200

Not only did Harte deploy Novaerus devices for TradFest but he also has encouraged bars and restaurants throughout Temple Bar, Dublin’s primary tourist district, to do the same. In fact, Harte won’t hold meetings in a room that is not continually cleaned by WellAir’s patented NanoStrike technology, which powers all Novaerus devices.

“I don’t feel comfortable breathing someone’s contaminated air,” he says. The public, he believes, is starting to feel the same way.

“When the world re-opens, people will make choices as to what bars and restaurants they’ll go into. And once people want it, you have to have it. Novaerus technology is like a fire extinguisher: You cannot safely run your business without it.”

Covid is here to stay in some shape or form, says Harte, “and we need to adapt. We’re not returning to normal any time soon.”

In the video below, Martin Harte, CEO of The Temple Bar Company, explains how TradFest Temple Bar reimagined their iconic event with the help of Novaerus air dis-infection technology from WellAir.

Download the full case study here.

Hear from customers in Ireland who have chosen WellAir’s Novaerus devices to protect the air for their staff and customers.

Yes, Covid-19 Aerosols Are Infectious, And More Dangerous than Droplets – Part 2

Read part one of this blog post here.

Infectious Aerosols: Small but Potent

Many Covid-19 precautions — plexiglass dividers, desks spaced 6 feet apart, reduced restaurant occupancy — are premised on the notion that large droplets, generated by sneezes and coughs, pose the greatest danger to vulnerable people.

In reality, the most dangerous droplets are the invisible ones, particularly those in the range of 2 μm to 3 μm.

Not only can aerosols hover for hours and travel across rooms, but they also carry more infectious virus than large droplets.

“Humans produce infectious aerosols in a wide range of particle sizes, but pathogens predominate in small particles,” explains Kevin Fennelly of the NIH.

This is true for influenza, SARS-CoV-2, and other respiratory viruses, says William Lindsley, PhD, a biochemical engineer with the U.S. Centers for Disease Control and Prevention.

“You see a lot more virus in small aerosols,” Lindsley told a panel at an international conference on the aerosol transmission of Covid-19.

This is because of where aerosols originate: in the lungs. Research shows the viral load of SARS-CoV-2 is higher in the lungs compared to the upper respiratory tract.

What makes aerosols so dangerous is that once inhaled, they can penetrate deeper into the lungs. For a patient to develop severe Covid-19 symptoms, such as pneumonia or acute respiratory distress syndrome, the virus must reach the lower airways, and only small aerosols can travel that far.

“We know that if the virus makes it down deeper into the respiratory system, fewer viruses are required to initiate infection, and this can also affect the severity of disease,” Marr reported at the international Covid-19 conference.

To those still sceptical that aerosol transmission is driving Covid-19 spread, NIH’s Fennelly responds: “There is no evidence to support the concept that most respiratory infections are associated with primarily large droplet transmission. In fact, small particle aerosols are the rule, rather than the exception, contrary to current guidelines.”

NanoStrike Technology: Fighting Aerosol Spread of Viruses

How can guidelines be updated to reflect the reality of aerosol transmission?

Healthcare facilities cannot simply rely on personal protective gear, hand hygiene, and cleaning protocols. And distancing protocols, whether implemented in nursing homes, offices, or pubs, are of limited use indoors; the 6-foot/2-metre rule does not stop aerosols from floating across a room.

With SARS-CoV-2 hovering, undetectable, what all indoor environments need is high-powered air dis-infection, such as Nanostrike technology from Novaerus.

Novaerus’ compact devices use a plasma field that obliterates pathogens at the molecular level, instantly rendering them inactive. The technology has been used in over 65 countries to help combat Covid-19, particularly in hospital operating rooms, intensive care units, emergency rooms, waiting rooms, and surgical theatres.

The Novaerus Defend 1050, cleared by the U.S. Food and Drug Administration as a 510(k) Class II medical device, has been proven in independent laboratory testing to filter out and inactivate a wide range of airborne viruses and bacteria.

Within 15 minutes, the Defend 1050 has demonstrated a 99.99% reduction of the MS2 bacteriophage RNA virus, an accepted surrogate for SARS-CoV-2. The device, like other Novaerus units, has shown similar efficacy with other airborne pathogens, including influenza, Clostridium difficile, Aspergillus, and surrogates for Measles virus, Tuberculosis and Methicillin-Resistant Staphylococcus Aureus (MRSA).

Upon obliterating pathogens, the Defend 1050, a portable, free-standing system, releases clean air back into the room. Unlike other technologies, which can pose risks to humans, Novaerus devices are safe for 24/7 use among the most vulnerable patients.

Though NanoStrike technology was designed for use in medical settings, Novaerus’ sleek, compact devices have also been installed in retail, hospitality, and office settings, from wine-tasting rooms to hotel lobbies, offering medical-grade protection to customers and staff alike.

From Measles to Covid-19

In 1982, one year after those seven American children contracted measles during a visit to the paediatrician, a similar outbreak occurred in another American paediatrics practice.

This time, three children contracted measles despite arriving at the doctor’s office more than an hour after the source patient had left the building.

And this time, instead of dismissing the incident as an outlier, scientists conceded that the conventional wisdom about measles likely had been wrong.

“Airborne transmission may occur more often than previously suspected,” a team of public-health physicians wrote in the Journal of the American Medical Association.

With regard to Covid-19, scientists have come to that conclusion more quickly. Now, building operators must make sure the precautions keep up with the science.

Yes, Covid-19 Aerosols Are Infectious, And More Dangerous than Droplets – Part 1

Covid-19 Aerosols Are Infectious, And More Dangerous than Droplets – Part 1

More and more evidence supports the case that Covid-19 Aerosols are infectious and more dangerous than droplets, in this blog post we take a look at how a similar debate was made around measles in the 1980s and how health officials reacted compared to how the health officials have reacted to the current Covid-19 pandemic.

In 1981, seven American children contracted measles during a visit to the same doctor’s office.

Three of the children had never crossed paths with the 12-year-old source patient. One child arrived at the office an hour after the infected boy had left.

The outbreak caused a stir. At the time, public-health authorities believed measles was transmitted via large respiratory droplets, the kind generated by phlegmy coughs, and required contact within about 1 meter of an infected person.

So ingrained was this belief that a major medical journal, Pediatrics, deemed the outbreak an outlier, concluding that for measles, “Infectious Aerosol spread is unusual.”

Of course, today we know the opposite is true. Microscopic measles particles can remain airborne and infectious for up to 2 hours and can drift far and wide. In one case, an infected athlete transmitted the disease to spectators 100 feet (30.5 meters) away. The notion that measles is primarily contracted through contact with large droplets, rather than via tiny, inhaled aerosols, has been thoroughly debunked.

One year into the Covid-19 pandemic, that same theory has been debunked with respect to SARS-CoV-2 transmission, though infection-control measures have lagged behind the science.

In one regard, the evidence supporting aerosol transmission for Covid-19 is actually stronger than it is for measles: Viable SARS-CoV-2 has been captured via air sampling, a feat that has yet to be achieved with the measles virus.

In fact, only one study, published in 2016, long after experts declared measles airborne, has captured measles RNA in the air — a study its authors called “the first study to directly detect evidence of airborne transmission of measles.” Yet in that study, testing in cell cultures failed to detect viable measles virus.

By contrast, at least six air-sampling studies have isolated SARS-CoV-2 RNA. And one, conducted at the University of Florida, proved SARS-CoV-2 viral particles — captured as far as 4.8 meters from a Covid-19 patient — were viable.

“If this isn’t a smoking gun, then I don’t know what is,” asserts Linsey Marr, PhD, a Virginia Tech aerosol scientist who was not involved in the study.

Marr calls the results “unambiguous evidence that there is infectious virus in aerosols.”

The Florida study, piled atop volumes of other evidence pointing to aerosol transmission, has intensified calls for more robust infection control indoors — in hospitals, nursing homes, dental practices, and retail establishments.

With ultra-contagious SARS-CoV-2 variants now surging globally, the stakes could not be higher.

“It is very clear that aerosols play a considerable role in the transmission of Covid-19 and that we are unlikely to prevail against this pandemic unless we acknowledge that fact,” asserts Justin Morganstern, M.D., a Canadian emergency physician, in an evidence review.

While physical distancing and masks remain important, Morganstern argues, “We should be looking at the extra precautions we can add to stem the spread of this disease.”

Foremost among these precautions should be air filtration and dis-infection, say experts, including Kevin Fennelly, M.D., of the U.S. National Institutes of Health.

At hospitals and nursing homes, infection-control protocols are based on “old data and inferences,” Fennelly asserts in The Lancet Respiratory Medicine. Droplet transmission is not driving the pandemic, he argues, and precautions should be updated to “account for the predominance of small particles within infectious aerosols.”

Covid-19 Aerosols are Infectious in the Air

At the pandemic’s outset, health authorities made the same assumption about SARS-CoV-2 that they’d made, erroneously, about measles in the 1980s and tuberculosis in the 1950s: that aerosol transmission, if it happened at all, was “probably very rare.”

But that assumption soon began to wither.

Quickly, it became clear that asymptomatic carriers were spreading Covid-19 in huge numbers, without sneezing or coughing.

What’s more, scientists identified outbreaks — on cruise ships and bus rides, at choir practices and ski resorts, in call centres, restaurants, and shopping malls — that could not be explained by surface or droplet transmission.

Strengthening the case for aerosol spread, scientists captured SARS-CoV-2 genetic material on surfaces that patients could not possibly have touched, such as air outlet vents and air-handling grates.

Even more compelling, coronavirus particles were captured in the air — above flushing toilets, in hospital nurses’ stations and changing rooms, in hallways outside patient rooms, and inside patient rooms beyond 6 feet from the patients.

Still, questions persisted: Was the RNA viable? Could the captured particles actually invade a cell, replicate, and trigger infection? Or were they inert, harmless fragments of genetic material?

The answer was elusive because aerosols, microscopic and fragile, are easily damaged by the air-sampling process.

But the University of Florida team used new, more sophisticated technology, preserving SARS-CoV-2 RNA captured in the air 15 feet from a Covid-19 patient. The genome sequence of the collected virus matched the sequence isolated from the patient.

The study, says lead researcher John Lednicky, PhD, proved “conclusively” that viable SARS-CoV-2 particles, small enough to be inhaled, can linger in the air and pose a risk to those in the vicinity.

The study squelched doubt that Covid-19 can spread — and readily — via aerosols.

Read part two here.

Infection Spread in the NICU: “The Tip of the Iceberg” – Part 2

COVID-19 aside, respiratory viral infections (RVIs) strike newborns particularly hard and, according to Austrian researchers, are “more prevalent in the NICU than previously considered.” RVIs are likely underdiagnosed, the authors assert, as many NICUs don’t routinely test for viral pathogens in symptomatic patients. Respiratory viral infections are a leading cause of mortality among newborns and often are detected only late in the course of illness.

Read part one of this blog post here.

Viral Outbreaks in the NICU

Though the majority of NICU infections are bacterial, nosocomial viral infections have been widely reported, including outbreaks of syncytial virus (RSV), influenza H1N1, rotavirus, adenovirus, enterovirus, and norovirus.

COVID-19 aside, respiratory viral infections (RVIs) strike newborns particularly hard and, according to Austrian researchers, are “more prevalent in the NICU than previously considered.”

RVIs are likely underdiagnosed, the authors assert, as many NICUs don’t routinely test for viral pathogens in symptomatic patients. Respiratory viral infections are a leading cause of mortality among newborns and often are detected only late in the course of illness.

The hospital costs of RVIs are particularly high. A 6-year study of a NICU in Nottingham, UK, found that compared to uninfected newborns, infected NICU patients spent far longer in the hospital — 76 days compared to 41 days — and in-hospital care costs were significantly higher, £49,664 compared to £22,155.

Infected NICU staff are often the source of viral outbreaks, especially influenza infection.

Newborns, of course, cannot be vaccinated, and annual vaccination rates among the healthcare workers who care for these patients are alarmingly low.

An H1N1 influenza outbreak in a Greek NICU, for example, was traced to the nursing staff, just 15% of whom were vaccinated.

“Nosocomial influenza can cause considerable morbidity, especially in high-risk neonates,” the authors wrote, “and is readily transmissible in the NICU setting by unvaccinated staff members.”

Viral infection spreads quickly in the NICU. A norovirus outbreak at Texas Children’s Hospital, traced to one newborn, began spreading within 24 hours and within two weeks had afflicted 28 babies, along with 12 staff members, who had to be furloughed.

Disinfecting the NICU Air, Safely and Quietly

Hand hygiene has long been the cornerstone of hospital infection prevention, in the NICU and elsewhere, and healthcare workers are striving to be even more meticulous in the COVID era. Yet hundreds of studies demonstrate that over the decades, compliance has been, in the words of the World Health Organization, “abysmally low.”

Surface cleaning, too, has been augmented since the emergence of SARS-CoV-2 but inevitably falls short, as airborne pathogens continually settle on medical equipment, floors, clothing, and healthcare workers’ hands.

It is impossible to operate [NICU] environments in complete sterility,” a University of California team reported. The infants themselves, the adults who care for them, the equipment required for their care — all represent “fertile vectors for microbial transmission.”

Though stringent cleaning protocols for NICU surfaces have been in place for years, infections rates remain stubbornly high.

“It is tempting to speculate that more potent cleaning techniques or agents will lead to further decreases in nosocomial infections,” the researchers concluded, but reality may be otherwise. “Future improvement may require innovative approaches.”

Among the most effective innovations is ultra-low-energy plasma technology by Novaerus, now deployed in NICUs and COVID wards worldwide. Easily installed on the wall, a shelf, or a rolling stand, Novaerus devices quickly destroy airborne viral, bacterial, and fungal particles.

For example, lab tests found the company’s most powerful unit can reduce the airborne load of MS2 Bacteriophage, a virus used as a surrogate for SARS-CoV-2, by 99.99% in just 15 minutes. The technology decimates MRSA load just as thoroughly and quickly.

Dis-infecting air in the NICU, as well as other wards and common areas, is imperative, as study after study points to hospital infection spread via aerosolization. A Japanese team, for example, reported on an outbreak of Bacillus cereus in its NICU, concluding the bacteria spread via the airflow of the ventilation system. Numerous studies have detected MRSA and Clostridicum difficile in hospital air.

As for SARS-CoV-2, air-sampling studies have detected viral RNA in hospital hallways and in rooms where healthcare workers changed their clothing, prompting the World Health Organization to finally agree with scientists worldwide that aerosol transmission of COVID-19 cannot be ruled out.

In a year-long study of an American NICU, a team of environmental engineers noted in PLOS One: “Hospital hygiene protocols may undervalue the potential importance of the airborne transmission route.”

Throughout hospitals, but especially in the NICU, ultra-low-energy plasma technology is an important addition to ventilation and filtration. Whereas conventional filters capture only large particles, Novaerus units destroy the smaller and deadlier ones.

Novaerus units run continuously and quietly, a benefit given the adverse effect of noise on the heart rates and respiratory systems of preterm or very low birth weight infants.

The technology is safe to operate around even the smallest, most medically fragile NICU patients, unlike other air-sanitation methods that can produce harmful byproducts.

Novaerus technology not only helps prevent infection but also mitigates newborns’ exposure to chemicals such as volatile organic compounds (VOCs) and particulate matter. Lacking the protective buffer of the womb, research suggests, newborns in the NICU are exposed to chemicals that may permanently alter neurobehavioral outcomes.

Air quality in the NICU may have a “significant impact on their long-term development,” note researchers at the Icahn School of Medicine at Mount Sinai in New York City, who are conducting the first study of air quality in neonatal intensive care.

Infants admitted to the NICU often stay for long periods, putting them at elevated risk for contracting an infection. The average length of stay for a term or near-term infant with surgical or respiratory issues is about 15 days; the length of stay for preterm infants born at 26 weeks’ gestation is more than 2 months.

Throughout their stay, it is imperative that their infection risk is reduced by stringent hand hygiene, effective surface cleaning, and 24/7 air dis-infection.

Microbes accumulate 24 hours a day, as visitors, staff, and medical devices come and go. Healthcare workers’ hands and NICU equipment cannot be cleaned continually, but with the installation of Novaerus technology, the air in the NICU can.