October 2012Volume 25, Number 5

What we think about, and what we’d like you to think about

Published as a community service by The Abell Foundation

The Abell Report

by Joann Rodgers, M.S.

Ultraviolet germicidal irradia-tion (UVGI), a technologycommercially available in the

United States for more than a century,destroys a lengthy list of disease-causing viruses, bacteria, and mold-making fungi by disabling their DNAand preventing reproduction—andit’s affordable and done without harshchemical disinfectants. The ultravioletcomponent of sunlight is one reasonthat microbes die faster outside thaninside, and when placed properly inand around the ducts and coils of air-handling systems, or in portable roomunits, UV light delivery systems are aproven means of preventing diseasetransmission and microbial contami-nation in biological laboratories, TBclinics, and “sick buildings.”

Ultraviolet radiation is an electro-magnetic wave discovered in 1801 byGerman physicist Johann WilhelmRitter, but was mislabeled as “chemicalrays” for more than a century becauseRitter identified them with an experi-ment in which silver salts turned blackwhen exposed to sunlight.

UVGI was first shown to disinfectwater in 1877, and in 1903, Danishphysician Niels Finsen won a Nobel

Prize for the use of UV radiation totreat smallpox and lupus. Experi-ments in TB sanatoria around thesame time demonstrated that UVdecreased both influenza and TBtransmission. Such promise led to theinstallation in 1909 of the first UVGIsystem for mass disinfection of thecity’s water system in Marseilles,France. Its use in disinfecting surgicaland medical equipment has been pop-ular ever since.

Such uses of UVGI are “commonand reliable,” according to WallyKowalski, Ph.D., a consultingmechanical engineer, expert on UVGI,founder of the field of aerobiologicalengineering while a member of Penn-sylvania State University’s architecturalengineering department, and aresearcher who has conducted dozensof studies examining ways to stop orkill resistant germs; and a colleague,William Bahnfleth, Ph.D., a currentPenn State professor and director of itsIndoor Environment Center. In sepa-rate interviews, both Kowalski andBahnfleth emphasized that UVGI airdisinfection showed so much potentialin the 1920s that experts were predict-ing the eradication of airbornepathogens and disease in hospitals andelsewhere. By 1936, UVGI was being

used in operating rooms, and studiesshowed that UVGI could stop thetransmission of TB in hospitals’exhaust air and reduce the transmis-sion of measles in schools.

In relatively simple terms, UVGI isan air, water, and surface sterilizationmethod generally produced by mercu-ry vapor light emissions. These emis-sions operate in one tiny wavelengththat is part of the germ-killing ultravi-olet C (UVC) electromagnetic spec-trum. (The wavelength measuresaround 253 nanometers, with ananometer being one-billionth of ameter.) UVGI emits about 85 percentof its light in the wavelength easilyabsorbed by DNA. UV light’s wave-length is much shorter than the lightwe can see, but it’s longer than x-rays.(The light spectrum consists of elec-tromagnetic waves with frequenciesgreater than what people see as the col-or violet, thus the name “ultraviolet.”)

Found naturally in sunlight, UVlight is visible to insects and birds, butnot to humans, and it produces chem-ical reactions that cause fluorescencein some materials such as black lights,and the increasingly popular “UVdrying lamps” used in nail salons tocure color gels and lacquers. In addi-tion to mercury, other UV sources

Green Technology to Fight Hospital-Linked Infections:A new study finds that although significant barriers exist to wider usage, the science ofultraviolet germicidal irradiation (UVGI) remains promising—a weapon in the

war against pathogens that kill patients.

2

that continuously emit invisible lightare xenon, deuterium, metal halide,and tungsten-halogen.

Under normal environmental con-ditions, the short wavelengths foundin UVC rarely reach Earth from thesun because the ozone blocks them,thus protecting the DNA of this plan-et’s inhabitants. But with UVGI tech-nology devices in circulating air orwater systems, the UV light energy isencased and harnessed. When placedproperly in HVAC&Rs (heating, ven-tilation, air conditioning, and refrig-eration), UVGI is able to killpathogens in ways that limit humanexposure to the radiation. In fact, sev-eral years ago, the U.S. General Serv-ices Administration required thatUVC be included in air-handlingcooling units for all new governmentfacilities to improve cleanliness andair quality.

So it would seem UVGI is an obvi-ous “must have” or “go to” technologyfor what are arguably this nation’smost persistently germ-ridden places:hospitals. Healthcare-acquired infec-tions (HAIs) pose lethal risks to mil-lions of patients, visitors, and medicalcare providers. Overall, they strike atleast 5 percent of all those hospitalizedin the U.S., including Maryland, withthat rate doubling in some intensivecare units. In 2010, the MarylandHealth Services Cost Review Com-mission put the number of “avoid-able” HAIs in the state at 14,206, at acost to insurers, taxpayers, andpatients of $175 million.

Considering the increasing ten-dency of hospital marketers to viewimproved patient safety and greensolutions as both life-saving upgradesas well as competitive edges, this onlyadds to the potential appeal ofUVGI. Dozens of companies makeUVGI units for air, water, room, andall-surface decontamination. Andwhat hospital administrator isn’teager for cost-effective ways to safelyreduce the use of liquid disinfectants,germicidal sprays, and mechanical fil-ters that create their own environ-mental problems and require pla-toons of housekeepers? “The avail-ability of smart, green technologiesfor HAI reduction certainly sparksour interest,” says Theressa Lee, chiefof the Hospital Quality Initiative atthe Maryland Health Care Commis-sion, a part of the Maryland Depart-ment of Health and Mental Hygiene.

However, to date, UVGI has large-ly failed in its bid to become a safetymeasure of choice for hospitals, or togain significant traction as an envi-ronmentally sensitive approach toreducing HAIs. Widespread agree-ment about UVGI’s effectiveness iselusive, while concerns about its safeuse and applicable standards remainabundant. Although there are no reli-able national figures documenting itsuse, those familiar with the industrysay at most only a few hundred hospi-tals out of the 5,754 nationwide useUVGI in significant ways. Accordingto the engineering firm of Leach Wal-lace, it has 60 hospital clients in Balti-more and around the country that useUVGI technology, with units in some

areas of Mercy, Maryland General,Sinai, St. Joseph’s, and a handful ofother state health-care institutions.But no UVGI systems have beeninstalled housewide in any major hos-pital, including Johns Hopkins’ new$1.1 billion clinical building in EastBaltimore, which opened in 2012.

Indeed, the history of UVGI sinceits first health application in the 18thcentury is one of seemingly endlesspromise, accompanied by disappoint-ment and disuse. The current consen-sus among hospital epidemiologists,facilities managers, mechanical engi-neers, medical and public health pro-fessional societies, government andacademic organizations, state regula-tors, and patient-safety researchers isthat UVGI, like the bridesmaid whonever weds, has perpetual prospectsand eager beaus, but is unable to getto the “I do’s.”

Reasons for UVGI’s small foot-print, like poet Stephen Leacock’sfabled horse, ride off in all direc-tions—and there is no shortage of fin-ger pointing. Depending on thesource, the causes are regulatory road-blocks, the absence of standard UVGIindustry specifications and compo-nents, hospital construction industrycomplacency, poor marketing, lack ofrigorous effectiveness research, andmisguided fear about UVGI’s safety.

While all of these factors have cre-dence, experts say, UVGI still haschampions—both scientific and com-mercial—who predict a resurgence ofinterest and applications. They agreeit is unlikely UVGI will ever be astand-alone solution to HAIs, but

continued from page 1

The Abell Report is published quarterly by The Abell Foundation111 S. Calvert Street, 23rd Floor, Baltimore, Maryland 21202-6174 • (410) 547-1300 • Fax (410) 539-6579

The Abell Reports on the Web: www.abell.org

they insist the technology deserves farmore respect than it gets, and that itstime is coming. But when?

In the fall of 2011, following areport of successful efforts to reducesome troubling infections in Mary-land hospitals [March 2011, TheAbell Report, Volume 24, Number 2],The Abell Foundation commissioneda detailed look at the status of theUVGI story, one highlighting theclaims, counterclaims, prospects, andlimitations proffered by championsand critics.

This is that report. It focuses onthe scope of the HAI problem, theevidence for and against the use ofUVGI as either a stand-alone or“adjunct” infection-prevention strate-gy, along with factors that keep Balti-more’s major medical centers—andmost of the state’s network of teachingand community hospitals—fromadopting UVGI and other greenerprotective technologies. This reportconcludes with recommendations formoving UVGI into the mainstream ofinfection-control plans and policies,gathered from reviews of the engi-neering and infectious disease litera-ture, and interviews with more than adozen people in the UVGI industry,academic engineering, hospital epi-demiology, health-care facilities man-agement, and patient safety in Mary-land and around the U.S.

SO MANY INFECTIONS, TOOLITTLE HEADWAY: A ROLEFOR UVGI?

It’s been more than a dozen yearssince the landmark Institute of Medi-cine book-length 1999 report, To Erris Human, declared unsafe medicalcare a significant national problem inneed of a “systems” approach to reme-diation, rather than a focus on indi-

vidual providers. In the interim,despite a long-time war on pathogens,fueled by bleach, ammonia, alcoholgels, HEPA filters, relentless hand-washing campaigns, regulatorythreats, and elbow grease, federal pub-lic health officials estimate 1.7 millionnew HAIs each year in the nation’stemples of healing, killing 100,000annually, and adding an estimated

$45 billion a year to rising health-carecosts and woe for already sickpatients, employer health plans, tax-payers, and hospital risk managers.

Despite vaccines, antibiotics,expensive isolation units, regulatoryand financial penalties, “cover yoursneeze please” signs, and countlessinfection-control projects attuned tothe latest behavioral science, epidemi-ologists who track the emergence,transmission, and spread patterns ofinfections know that a trip to the hos-pital still means exposure to viruses,bacteria, and mold-building fungal

spores that are easily airborne, andcapable of riding on the products ofsneezes, coughs, and moving air tosicken the vulnerable.

Abetted by antibiotic resistance,air-, water-, and surface-borne infec-tions caused by streptococcus, methi-cillin resistant Staphylococcus aureus(MRSA), Clostridium difficile, influen-za virus, pseudomonas, aspergillus,Legionella, vancomycin resistant ente-rococcus (VRE), and other nasties onthe “most wanted” lists of hospitalinfection trackers, remain frustratinglyresistant to eradication.

Studies show some germs surviveon surfaces for days, weeks, ormonths, waiting for the haplesspatient, visitor, physician, nurse, orhousekeeper to pick them up from aroom phone, an ice machine, a waterfaucet, or a bed rail and spread themaround, and numerous studies have linked room contamination topatient infections.

Even discounting SARS, H1N1,and other emergent infections withnew or no names, Maryland hospitalsare under especially persistent dailythreat not only from the bugs namedabove, but also from noroviruses,rotaviruses, Norwalk viruses, the virus-es that cause hepatitis, and mycobacte-ria like the one that causes TB.

The March 2011 Abell Report,which compiled rates for one type ofHAI in Maryland, noted that, com-pared to 16 other states whose datawere made public by the U.S. Centersfor Disease Control (CDC) in 2010,the Free State’s rates were “troubling,”ranking worst among the group. Thatsame year, the Maryland Health CareCommission (MHCC) also publishedcomparative rates for this HAI,known as CLABSI, or a central lineassociated bloodstream infection,

3

▲

UVGI would seem to be an obvious“must have” or

“go to” technology for what are arguably

this nation’s most persistently germ-ridden

places: hospitals.

▼

measuring each institution against“national benchmarks.” Of 45 hospi-tals cited in that report, eight, includ-ing University of Maryland MedicalCenter, Sinai Hospital, and JohnsHopkins Bayview Medical Center,had pediatric and adult infection ratessubstantially worse than similar insti-tutions nationally.

CLABSIs are generally caused bygerm-contaminated plastic tubes thatare placed in patients to deliver drugs,and to sample blood and other fluids.All told, they account for 15 percentof HAIs and 30 percent of the CDC-estimated 100,000 deaths a year fromthese infections.

To be fair, not all hospitalsnationwide report their HAIs, andthose states that also audit and verifycases (just five including Maryland)predictably show higher infectionrates because these states go lookingfor cases and for evidence of under-reporting. The shortcomings of datacollection notwithstanding, however,public-health policy makers, patient-safety gurus, and infection-control specialists say it’s clear thatefforts to prevent or control trans-mission of infectious agents, particu-larly among the immune-compro-mised, the frail elderly, the veryyoung, and the very sick, are notworking to anyone’s satisfaction.

“It’s unacceptable that infectionsstill kill more people in hospitals thandie of breast cancer in the U.S.,” saysPeter Pronovost, M.D., a Johns Hop-kins University critical care specialist,internationally recognized patient-safety researcher, and director of theArmstrong Institute for Patient Safetyat Johns Hopkins. “Every hospital killspatients with infections,” whether

they acknowledge it or not, he says,via pathogens transmitted throughthe air, water, and contamination ofmedical equipment and devices.Pronovost’s widely publicized operat-ing room “checklists” have significant-ly reduced central line and surgicalsite infections (SSIs) at hospitals in

the U.S. and abroad, and rates ofCLABSI in Maryland hospitals havedeclined significantly, according tothe Maryland Health Care Commis-sion. Yet Pronovost’s colleague, JohnsHopkins surgeon Martin Makary,

M.D., has conducted a study showingthat SSIs alone still kill about 8,000patients a year and cost the health-care system roughly $10 billion.

“Cleaning water, surfaces, andequipment in hospital rooms, ICUs,and ORs is imperative, and we aredoing a better job, but all of our datasuggest that the kind of cleaning wedo is not enough despite Herculeanefforts,” says Trish Perl, M.D., MSc,former president of the Society forHealth Care Epidemiology of Ameri-ca (SHEA), professor of medicine atJohns Hopkins University, and chiefepidemiologist for The Johns Hop-kins Hospital and Health System.Because of human behavior and clini-cal engineering factors, she says, stud-ies show that adequate cleaningoccurs in hospitals only 49 percent ofthe time, and the risk of infection in aroom previously occupied by peoplewith certain infections is close to 4percent. “Even with improved disin-fection and systematic cleaning, trans-mission of infectious organisms stilloccurs,” she says, and even such basicpreventive measures as consistent andfrequent hand washing by medicalpersonnel fall substantially short ofthe 100 percent goal.

Reporting in the journal InfectionControl and Hospital Epidemiology in2011, a team of researchers at theCenter for Evidence-Based Practice atthe University of Pennsylvania pub-lished results of a 2011 study lendingsupport to Perl’s glum assessment.Estimating the proportion of HAIs inU.S. hospitals that are “reasonablypreventable,” the Penn team foundthat only 65 to 70 percent of CLAB-SIs similarly caused urinary tractinfections, and ventilator-associatedpneumonias are likely preventable“with current, evidence-based strate-

4

continued from page 3

▲

“It’s unacceptable that infections stillkill more people in

hospitals than die ofbreast cancer in theU.S.,” says PeterPronovost, M.D., a Johns Hopkins

University criticalcare specialist, internationally

recognized patientsafety researcher, and

director of the Armstrong Institutefor Patient Safety at

Johns Hopkins.

▼

5

gies.” The researchers concluded that“100 percent prevention of HAIs maynot be attainable…” without differentor additional preventive measures.

At the root of the HAI problemare germs that already are colonized orgrowing in the many nurturing envi-ronments and bodies in a hospital,compounded by those walked,wheeled, or carried in by the sick, thewell, ambulance personnel, andequipment, and the air and waterpumped through spaces, ducts, vents,and pipes. Cross contamination is vir-tually a continuous threat andalthough physicians, nurses, and oth-er hospital personnel can always domore to practice optimal hygiene toprotect patients and themselves, it’s aSisyphean task to keep up with whatmay come inside every time a dooropens or a cough erupts.

The scientific literature teems withstudies demonstrating that transmit-table pathogens lurk and grow onbedrails, blood pressure cuffs, tables,TV remote controls, toilet seats, care-givers’ hands, surgical tools, ventila-tors, diagnostic equipment, door han-dles, floors, walls, vents, ducts, refrig-eration coils, drain pans, fountains,and IV pumps. Legionella and otherorganisms often find welcome nichesto grow in ice makers, water foun-tains, and spigots, and hospitals don’thave full control of urban water sys-tems that can be periodically contam-inated by plumbing failures and mis-connections, or the backflow of wastewater that gets through preventivesystems before it comes into the hos-pital. Whirlpools and showerheadsalso have all been found to nurtureLegionella and other pathogens, andsuch devices often are resistant to

bleach flushes. One recent study showed that

MRSA could be cultured from 42 per-cent of gloved hands that nevertouched a patient but did touch con-taminated surfaces; and that 46 per-cent of cultures taken from bare handsgrew VRE after just five seconds ofcontact with a bed rail or table in aroom with VRE infection. One touch,or one sneeze, or one cough is enoughto send droplets of infection aloft tosettle abroad on surfaces in a room oron others’ bodies and clothing.

Further adding to the problem isthe capacity for bacteria and viruses toalter their DNA (mutate), adapt, andbecome resistant to drugs and somedisinfectants. Recent studies of bacte-ria discovered in a U.S. cave in NewMexico show that even bugs that nev-er came in contact with people, theirinfections, or their antibiotics areresistant to such drugs—evidence thatsupports the argument that microbialresistance is “natural and ancient” andthat even greater caution in use ofantibiotics won’t overcome the capac-ity for germs to win the day. Regard-less of when and how bacteria, fungi,and other bugs learned to persist byaltering their DNA or developingarmor, their lethal efficiency aweseven those sworn to destroy them,and suggests that current infection-control efforts are still too much likebringing a knife to a gunfight.

“The super bugs that you are hear-ing about are mostly these gram-negatives that are pretty much acquir-ing resistance to all known antibiotics,and we have nothing to treat themwith,” says Luis Ostrosky, M.D., aninfectious disease expert at the Uni-versity of Texas Health Sciences Cen-ter in Houston Medical School.Among these are Klebsiella pneumoni-

ae and actinobacter. Also particularlymenacing, Ostrosky says, is the hard-shelled bacterium Clostridium difficileor “C. diff ” in the shorthand parlanceof his field. C. diff infections aregram-positive (so named because theyreact positively to the so-called Gramstain test), and caused by bacteria thatproduce endospores whose toxinsattack the intestinal lining. C. diff isextremely hard to get off of barehands with soap and water, detergentswith ammonia, or alcohol-based handsanitizers. Some 30,000 are believedto die of C. diff infections each year inthe U.S., and public health officialsreport that illness caused by C. diff—first discovered in 1978—is fast out-pacing rates of MRSA infections incommunity and large hospitals alike.

Although a small number of peoplecome into the hospital carrying C. diffspores in their GI tracts, many moreacquire them through “oral fecal” con-tamination during their inpatient stay.Patients touch a service, utensil, door-knob, or other surface and pick up C.diff spores, then take a sandwich fromtheir food tray and without washingtheir hands, eat it.

Noroviruses, the bugs that haveripped through cruise ships in recentyears, can similarly live on dry sur-faces for up to three weeks and havebecome the second leading cause ofdeath from GI causes and a virulentthreat to the elderly and the veryyoung. Bacteria such as acinetobacterand staphylococcus have been knownto survive on surfaces for as long asfive months.

“Hospitals may be good at clean-ing surfaces and equipment for cer-tain bacteria and viruses, but C. diffspores survive on floors, can be kickedaround by mops, walking, and airhandling,” says Wally Kowalski, the

continued from page 4

consulting engineer. “Aspergillus, afungus, can blow in doors and win-dows, find receptive environments incarpets and in ORs, and are veryhearty and resistant to cleaning,”Kowalski adds. “Doctors and nurseswalking from a hallway into an oper-ating room bring spores in with theirbooties. And the sad fact is that hospi-tals can’t even keep up with testing andsampling of biofilms and other stuffalready on their floors, in their airvents, on tables, and on instrumentsurfaces, so there are few accuratebaseline data to even measure resultsof actions they are already taking.”

So complex are the ways andmeans of microbes and efforts to con-trol them that infectious disease spe-cialists long ago developed the so-called Spalding classification of disin-fection resistance to sort them out bycreating lists that describe hospital-linked germs in terms of their submis-sion to standard cleaning.

Bacterial endospores such asC.diff, a gram-positive anaerobicbacillus spore-forming organism(meaning it thrives best in no- or low-oxygen settings), are, along withnorovirus, the pathogens most resist-ant to standard disinfection withchemicals and to heat. Active onlywhen no oxygen is present, C.diffbecomes dormant when exposed toair but survives in endospore form,ready to grow again when it gets tothe gut or stomach. Both norovirusand C.diff are considered the ultimatehealth-related pathogen because bothcontaminate the environment, areresistant to disinfectants, and arespread by diarrhea, making them hardto clean.

The next category of resistance is

comprised of mycobacteria, rod-shaped aerobic bacteria that includetuberculosis germs. Their waxy outerlayer makes them tough to kill, too,and they have been especially trou-bling in devices such as bronchoscopesand other invasive tubes and devices.

Continuing in descending order ofresistance to standard disinfection,there are small, so-called non-enveloped viruses (viruses without aviral coating that infect cells more eas-ily) that include noroviruses, followedby fungi, which include molds andyeasts. Then come gram-negative bac-teria such as Acinetobacter baumaniiand Klebsiella pneumoniae; large, non-enveloped viruses such as rotaviruses(a frequent difficulty for children inday-care centers); gram positive vege-tative bacteria including MRSA andVRE; and—the most susceptible todisinfection—enveloped viruses,including blood-borne pathogenssuch as HIV, hepatitis B and C, andinfluenza A.

Compared to C. diff and otherbacteria and fungi, the viruses are rel-atively easy to kill, including thosethat cause HIV, hepatitis B and C,and the flu. Disinfectants (i.e., liquidchemicals such as alcohols, bleach,phenols, aldehydes, and ammonia),when used properly, can take most ofthem out.

Federal agencies and infectiousdisease academies have, over the years,developed protocols for scrubbingsurfaces, air, and water of bugs at eachlevel of the Spalding classification. Atthe “most resistant” level of germs,conventional cleaning and disinfec-tion may include sterilization withhot steam, peroxide gas, and alcohols.Moving down the spectrum, effectivecleaning can be had with heat, variousperoxides such as peracetic acid, chlo-

rine bleach, air-drying enzymaticdetergents, soap, and even sterilesaline and clean water. “Dilution isthe solution to pollution,” goes onemedical rubric.

What the statistics and studiesconsistently demonstrate, however, isthat even with the best use of avail-able, standard cleaning and disinfec-tion, HAIs continue to do enormousdamage. Hopkins’s Perl says addition-al ammunition is almost certainlyneeded to supplement or replace cur-rent weapons of mass germ destruc-tion such as various concentrations ofliquid bleach; disinfectant-soakedcloths and sponges; HEPA filters; spe-cial negative pressure air flow rooms;

6

continued from page 5 ▲

“The super bugs thatyou are hearing about

are mostly these gram-negatives that

are pretty muchacquiring resistance toall known antibiotics,and we have nothingto treat them with,”says Luis Ostrosky,M.D., an infectiousdisease expert at theUniversity of Texas

Health Sciences Center at Houston.

▼

and protective masks, gowns, gloves,and booties.

“The outbreaks we see here inMaryland and across the nation,” Perlsays, “suggest that additional measuresare sometimes required, especiallywith organisms that have a predilec-tion for the environment. The realquestion is where we go from here andcan UVGI help.”

THE HEALTH-CARE INDUSTRY RESPONDS

Unsurprisingly in an entrepreneur-ial nation, entire “patient safety”industries have emerged to documentand abate the HAI problem, marshal-ing all manner of prevention andcleaning strategies and producing anavalanche of publications, workshops,and guidelines designed to sell prod-ucts that ostensibly help hospitals andother health-care facilities select, test,install, implement, refine, or developinfection-preventing methods of airhandling, water treatment, and sur-face cleaning.

The response is due in no smallpart to market and regulatory pres-sures forcing hospitals to compete onthe basis of quality improvement,treatment “outcomes,” and overallpatient safety. “Hospitals have a big-ger interest these days in promotingsafety and defending against risk,”including the risk posed by HAIs, saysChris McCarthy, a mechanical engi-neer and senior vice president atLeach Wallace, whose firm hasinstalled UVGI lamps in the new chil-dren’s center at Baltimore’s Sinai Hos-pital, at the Baltimore WashingtonMedical Center’s new patient tower,and in parts of the central air-handling systems at Baltimore’s St.

Joseph’s Hospital and Maryland Gen-eral Hospital. “Hospitals like saying‘we have done all there is to do’ to pre-vent or stop the spread of infection,”McCarthy adds.

There is no dearth, either, of stateagencies, nonprofits, professionalsocieties, and voluntary organizationsmobilized to address HAI rates. InMaryland, the MHCC, the HSCRC,the Maryland Hospital Association,and individual hospitals are uppingthe ante, setting progressively tougherstandards for safety and quality. TheMaryland Patient Safety Center, thedesignated state patient-safety organi-zation and one of 25 organizations inthe nation listed as a Patient SafetyOrganization by the federal Agencyfor Healthcare Research and Quality,is especially focused on reducing cen-tral line infections and MRSA.

Organizations like the LeapfrogGroup, along with state governmentsand professional academies havebegun serious efforts to develop andpublicize infection-control “best prac-tices,” and publish successes and fail-ures. Among other entities rampingup infection control, quality improve-ment, and patient safety are SHEA;LEED (Leadership in Energy andEnvironmental Design); andASHRAE, the American Society forHeating, Refrigeration, and Air Con-dition Engineers.

The Leapfrog Group is a voluntaryprogram formed in 1998 to mobilizeand reward hospitals for “big leaps inhealth-care safety, quality, and cus-tomer value,” as the organization’swebsite describes its mission. Drivenby the Institute of Medicine’s To Err isHuman report, and the desire of largeemployers to reduce health-care costswith evidence-based standards,Leapfrog has made infection control

one of its major initiatives. Its strate-gy, similar to that of the Joint Com-mission, which asks hospitals to sub-mit to “voluntary” inspections and“corrective actions” to improve per-formance, prods institutions to meas-ure problems, solve them, audit cor-rective activities, and share whatworks with other institutions. It’s aprogram that is big on measuringthings, and a 2008 survey fromLeapfrog found that 87 percent ofhospitals fail to consistently practiceinfection-prevention measures.

SHEA was established in 1980 andhas thousands of members nation-wide. It sponsors research into HAIcontrol, and produces guidebooks andresource manuals for hospitals andpatients. Its popular “Compendiumof Strategies to Prevent HAI in AcuteCare Hospitals,” issued in 2008,focuses especially on central linebloodstream infections, catheter-associated urinary tract infections,ventilator-associated pneumonia, andC. diff. The organization also coordi-nates research and outreach effortswith the Infectious Diseases Society ofAmerica; the American HospitalAssociation; the Joint Commission;and the Association for Professionalsin Infection Control and Epidemiolo-gy (APIC), which is a 14,000 memberassociation of “infection prevention-ists,” physicians, nurses, epidemiolo-gists, and lab technicians.

LEED, established in 1998 by theU.S. Green Building Council, pro-motes and implements a standardizedrating system for the design, construc-tion, and operation of green build-ings, including hospitals. Companiesand institutions that adopt greentechnologies can earn “LEED Cred-its” and certifications, a kind of third-party “validation” that adds value in

7

continued from page 6

8

the marketplace. In central Maryland,Baltimore Medical System, a federallyqualified health center, has earned aplatinum LEED rating, for example,for its commercial interiors at one ofits facilities. Maryland’s Health Carefor the Homeless (HCH) hasachieved gold LEED status for greentechnologies, including the installa-tion of UVGI in its building’s air-handling system in a bid to reduce airborne transmission of acute respira-tory infections, prevalent in the population that HCH serves.

ASHRAE, a 50,000-member inter-national technical society with head-quarters in Atlanta, is widely consid-ered the leading organization forestablishing gold standards in heating,ventilation, air conditioning, andrefrigeration (HVAC&R) buildingand engineering standards, includingair handling and safety in hospitalsand other health-care facilities. Its “sealof approval” on novel technologies iscritical to the success of those tech-nologies in the marketplace.

ASHRAE’s impact on professionalawareness of HVAC-R-linked HAIs isgrowing. In January 2012, for exam-ple, an outbreak of Legionnaires’ dis-ease—caused by the gram-negativeaerobic bacterium Legionella pneu-mophilia and spread through inhala-tion contact with the germ in contam-inated water—was traced to a Mil-waukee hospital’s decorative “waterwall” lobby fountain. Eight peoplewere sickened; three required intensivecare and mechanical ventilators. Waterwalls produce sprays that can spewbacteria-filled water droplets into theair, where they are inhaled. Water col-lecting in the base of fountainsbeneath rocks and Styrofoam founda-

tions are also a problem to clean, andsome fountains are heated, adding to anurturing bacterial growth environ-ment. An official at the Wisconsinhospital, Aurora St. Luke’s SouthShore, said one piece of foam wasfound to house a million bacteria.

In a study of the outbreak reportedin Infection Control and Hospital Epi-demiology, a SHEA publication, ateam of epidemiologists said it was thesecond documented outbreak ofLegionnaire’s in a health-care facilitywith a water wall. It noted that suchfountains may be desired amenities,but they also are a rich environmentfor pathogens; and that even after rig-orous cleaning with bleach and otherdisinfectants, people with underlyingmedical conditions get sick. In a wide-ly hailed follow up, the CDC said itsexperts would work with ASHRAE todevelop standard practices for buildingmanagers to prevent disease by eitherremoving the fountains or adding nov-el technologies like UVGI to makethem safer. (The Wisconsin hospitalturned the fountain into a planter.)

Other organizations and profes-sional societies with a hand in thepatient-safety, infection-preventionindustry include the AmericanNational Standards Institute and theAmerican Institute of Architects,which publishes an industry bible,Guidelines for Design and Constructionof Hospitals and Healthcare Facilities.

Arrays of devices and novel infec-tion-control strategies have emergedfrom all of these groups and individualacademic engineers. These includeexperimental and FDA-approved vac-cines for hepatitis, various influenzas,and rotavirus; silver-coated and hydro-gel-coated catheters designed to reducecontamination; sterile lubricant jelliesto reduce transmission of catheter-

related infections; and automatedalerts and reminders to systematizecleaning and hand-washing behavior.

Hospitals are testing pre-operativebathing by patients themselves withchlorhexidine-soaked pre-packagedtowelettes; routine screening forMRSA upon admission; intranasaland throat disinfectant sprays ofpatients undergoing intubation; anti-septic-impregnated endotrachealtubes; and antibiotics “locks” to fillthe openings of catheters at the pointwhere they are inserted into a bloodvessel or body cavity.

It’s worth noting that while manynovel and green technologies arepromising, some have unintendedconsequences. A case in point testedrecently: “no touch” electronic-eyewater faucets. Reducing contactbetween germy hands and equipmentwould seem to reduce germ counts.But when researchers at Hopkinsactually checked, they found thatelectronic faucets were more likely,not less, to become contaminatedwith high levels of bacteria, includingLegionella, when compared with tra-ditional, manually operated faucets.

The faucets are increasingly popu-lar because they use less water. ButEmily Sydnor, M.D., an infectiousdisease graduate fellow who conduct-ed the Hopkins study, said when shecompared 20 manual faucets with 20new electronic ones, each gettingwater from the same source, bacterialcultures showed that 50 percent ofwater samples from electronic faucetsgrew Legionella compared to 15 per-cent from manual faucets. The lop-sided results persisted even after usingchlorine dioxide to flush the watersystem. Sydnor speculates that theproblem in electronic faucets may bedue to contamination of the many

continued from page 7

parts and valves that make up theirinnards compared to the simplermakeup of manual spigots.

Clearly, health-care industries arepaying attention to HAI. But equallyas clear is that consistent use of stan-dard disinfection; efforts to accuratelymeasure rates of infection; and usefulcomparisons of cleaning strategies,technologies, and protocols are a“sometimes” thing. Consequently,there is more than enough room foradditional technologies that showpromise in reducing HAIs. And UVGIis certainly among the nominees.

ULTRAVIOLET GERMICIDALIRRADIATION: THE PROM-ISE, THE PROBLEMS — ANDA FEW PERILS

Along with other technologicalsolutions, UVGI in the U.S. andabroad is the subject of renewed inter-est arising from a growing under-standing that while HAIs are spreadaround in a variety of ways, many ofthe worst are of the airborne variety ofinfectious pathogens, all too easilytransported through air-handling sys-tems, known to mechanical engineersas HVAC (for heating, ventilation,and air conditioning) and sometimesas HVAC&R (the “R” added toinclude refrigeration) systems. Thesesystems are comprised of ducts, coils,drains, pans, fans, and vents thatstream and refresh heated and refrig-erated air.

To stop the circulation of thesebugs at the source is understandablythe holy grail of any optimal infec-tion-control strategy, so much so thatthe CDC and other groups now con-sider it standard practice for hospitalsto use High-Efficiency Particulate-

Arresting (HEPA) filters, usuallymade of randomly arrayed fiberglassfibers that, like a sieve, trap bacteria,viruses, and molds greater than 0.3microns. If installed, cleaned, andchanged properly and regularly, theycan—under ideal circumstances—remove 99.7 percent of the most com-mon pathogens that plague hospitalpatients, visitors, and staff.

The problem is, however, thatsuch filters—even at that rate of effec-

tiveness—give tens of thousands ofmicrobes access to hospital air andsurfaces. Filters also break down, andbecome contaminated even when reg-ularly cleaned with disinfectants.Mechanical engineers and microbiol-ogists have long established that dis-

ease microbes can grow inHVAC&Rs, forming biofilms on thecoils that also increase the pressuredrop; decrease heat transfer; increaseenergy consumption; and spewpathogens into room air in hospitalpatient rooms, operating rooms, laboratories, intensive care units, andpublic spaces. Once colonized withbacteria, fungi, viruses, and molds,air-handling systems become a “reser-voir” of ongoing disease transmission.

As computer models provide moreaccurate ways to track and predicthow pathogens spread through the airin enclosed spaces and ventilation sys-tems, it is no surprise that many archi-tects, infection-control specialists, andhospital safety engineers haveembraced the potential of ultravioletlight technologies that—at least incontrolled conditions in the laborato-ry—have achieved a 99.995 percentkill rate in HVAC&R systems whenadded to HEPA filters.

Today, dozens of companies offercommercial—off the shelf or cus-tomized—UVGI HVAC&R unitsand systems, marketing them undersuch trade names as Steril-Aire, Klean,Germ-O-Ray, Lumalier, Solarair, Vig-ilair, Biozone, Airguard Industries,Ultraviolet Devices, Medical Air Solu-tions, and American Ultraviolet.

In Maryland, Mt. WashingtonPediatric Hospital, Sinai Hospital,Health Care for the Homeless, andBaltimore Washington Medical Centerare among the organizations that havealready installed UVGI lamp systemsin the air-handling systems of somebuildings, operating rooms, or otherhospital and clinical areas. Portableunits have been used in laboratories,operating rooms, and isolation wardsand rooms, and to clean empty ambu-lances and waiting rooms in other area

9

continued from page 8

▲

Hospitals can’t evenkeep up with testing

and sampling ofbiofilms . . . already

on their floors, in their air vents, on tables, and on

instrument surfaces,so there are few

accurate baseline data to even measureresults of actions theyare already taking.

▼

10

hospitals and emergency rooms.Companies in the UVGI industry

promote their technology as “green”or at least “greener” than other disin-fection methods, arguing that UVGIunits lower energy costs and operatingcosts. They say that UVGI is especial-ly good at eliminating biofilms, theyucky coatings that collect on coilsand in air ducts and vents comprisedof a woven matrix of bacteria, viruses,mold, dust, and dirt.

Steril-Aire, a company based inBurbank, CA, is in many ways typicalof the UVGI industry’s players in thatit includes infectious disease expertsand engineers in the ranks and execu-tive suite, relies heavily on testimonialsfor marketing, and struggles to differ-entiate itself in a fragmented market-place. The company manufactures andinstalls UVGI emitters directly intoHVAC&R systems. Although theU.S. Food and Drug Administrationwill not allow companies to say pub-licly that their lamps kill particularmicro-organisms until each companypublishes proof of the claims in clini-cal conditions—precious little data areavailable to that end—Steril-Aire offi-cials say privately that its products killall micro-organisms, “includingLegionella and probably anthrax.”

Steril-Aire also claims that UVGIis the best means hospitals have ofcontinuously cleaning coils, drainpans, and ducts of germs, and makingit safer to reclaim water from refriger-ation coils and other sources that canbe reused for flushing and irrigation.Its UVGI units, say company officials,also contribute to LEED certificationand pay for themselves in mainte-nance and operation cost savings in anaverage of two years. In addition, the

company’s website contains customertestimonials and claims that UVGIreduces HAIs, cross contamination,hospital lengths of stay, and liability.

Robert Scheir, Ph.D., a medicalmicrobiologist who worked as a spacebiologist in the aerospace industry andfor pharmaceutical companies, is a salesexecutive with Steril-Aire, and one ofUVGI’s most vigorous champions.

“UV technologies have beenaround more than 100 years,” he says,“but it’s only with the emergence ofair conditioning systems in recentdecades that an awful lot of bacteria,viruses, and molds found a nice homein their coils and drain pans.”

Underscoring the various nuances,complexities, and distinctions amongthe myriad UVGI systems on themarket, Scheir notes that old-style,traditional UV systems placed intocold moving air lose their effectiveness

over time and work for only a fewmonths before needing replacement.

THE RISKS OF UVGI In addition to the shortcomings of

UVGI mentioned previously, thereare safety concerns as well. If notproperly shielded, UVGI can cause illeffects because it is not blocked byozone. Portable UVGI units in somehospital settings have been removed atthe request of physicians, nurses, andhousekeepers because of concernsover burns and other side effects, orare turned on only when humans arenot in the line of fire.

Overexposure to all UV light, butespecially the relatively high-energyUVC rays, can cause melanoma. In2011, the World Health Organization’sInternational Agency for Research onCancer classified all UV radiation as aGroup 1 carcinogen, meaning there isevidence to show it can cause humancancer. In addition to the cancer threat,UVC light along with other forms ofUV light (UVA and UVB) have beenfound in various studies to damageconnective tissue, accelerate skin aging,redden the skin, aggravate lupus androsacea, and lead to cataracts. A 2009article by scientists at the M.D. Ander-son Cancer Center in Houston and theUniversity of Texas Medical School,published in the journal Archives ofDermatology, reported two womenwho developed skin cancer on thebacks of their hands from repeatedexposure to UV nail lamps. Even fluo-rescent lamps produce damaging UVradiation by ionizing low-pressuremercury vapor. A coating on the insideof the tubes, however, absorbs the UVand converts it to visible light. (InUVGI systems, there are protectivemechanical coverings, but to preventharmful exposure, people need to be

continued from page 9 ▲

Companies in theUVGI industry promote their technology as

“green” or at least“greener” than otherdisinfection methods,

arguing that UVGI units lowerenergy costs and operating costs.

▼

out of the room or distant from theunits when they are in use.)

Notwithstanding such largely pre-ventable risks, the more pressingproblem facing the UVGI industry’slack of wider acceptance in hospitals,according to Kowalski and Bahnfleth,is that unlike water and equipmentdisinfection applications, “the disin-fection of air streams using UVGI hasa history of varying success andunpredictable performance.” Despitetestimonials and a century worth oflaboratory tests showing that UVGIkills the DNA of disease germs, thepublished, peer-reviewed data are rel-atively scarce, they note, and theresults are often flawed or ambiguous.Some are very positive; none is a dealbreaker; but most contain seriouscaveats. Here’s a sampling:

• Industrial scientists at the Universi-ty of Tokyo, in a report publishedin 2010 in the ASHRAE journalHVAC&R Research, tested the dis-infection performance of UVGIsystems for microbial contamina-tion on an evaporative humidifier.Bacteria and fungi were isolatedfrom the surfaces and drain waterof the humidifier, and airbornemicrobes coming from the con-taminated unit were identified.After using UVGI in the humidifi-er’s duct works for six months, theresearchers reported that “micro-bial contamination was reduced,”but microbes could still “consis-tently be isolated from the surfacesand drain water. This was likelydue to internal contamination ofthe humidifier beyond the reach ofthe UVC band irradiation.”

• In an article published in the Jour-nal of Perinatology in 2011,researchers described a pre- andpost-UVGI intervention study inthe neonatal intensive care unit(NICU) at The Women and Chil-dren’s Hospital of Buffalo. The sci-entists set out to test the hypothesisthat enhanced UVGI installed inthe NICU heating ventilation andair condition system woulddecrease microbes, and trachealcolonization and ventilator-associ-ated pneumonias among the high-risk infants in the unit. The teamconcluded that UVGI “was associ-ated with reduced NICU environ-mental and tracheal microbial col-onization,” but also cautioned thatthe study was limited by the factthat the children could not be ran-domized, i.e., separated intogroups that were treated in UVGIbeds and not treated in UVGIbeds. The authors of the study, oneof whom is married to the formerCEO of Vigilair Systems, also not-ed that “concepts of airborne trans-mission of hospital infection areevolving,” and that “often over-looked” is the capacity of microbesto undergo “genetic repair and sec-ondary rehydration with ambienthumidity that virtually ensurespread of disease….”

• In a study of UV light used to dis-infect hospital water, Barry Farr,M.D., an epidemiologist at the Uni-versity of Virginia Medical Center,collected 13 years’ worth of infor-mation on rates after a new hospitalopened with UVGI systems inplace. Some 27 percent of watersamples from taps in the old hospi-tal contained the bacteria. Not a sin-gle one of the 930 cultures of new

hospital water taps (as of 2003 whenhe published the study) were posi-tive for Legionella. Although somepatients developed the infection,none was from hospital water, andmost were brought into the hospi-tal. Farr and his team concludedthat “ultraviolet light usage wasassociated with negative water cul-tures and lack of clearly document-ed nosocomial Legionella infectionfor 13 years at this hospital.”

• In a study in a tuberculosis ward inLima, Peru, researchers from theWellcome Trust Centre for ClinicalTropical Medicine at Imperial Col-lege London in 2009 hung UVClamps in areas housing 69 patientsundergoing treatment for HIV andTB. Researchers pumped air fromthe ward up to a guinea pig enclo-sure on the roof of the hospital for535 consecutive days. The guineapigs were split into three evengroups: The first got air exposed toUV lights; the second got air treat-ed with negative ionizers, air puri-fying equipment that uses highvoltage to electrically charge airmolecules and essentially manufac-tures static electricity to trap partic-ulates; and the third got untreatedair straight from the TB ward. Theguinea pigs were skin-testedmonthly for TB antibodies. By theend of the experiment, 35 percentof the guinea pigs exposed to directward air got infected, compared to14 percent of the ionized air groupand 9.56 percent of the UVC-exposed group. The team conclud-ed that UV lights could reduce thespread of TB in hospital wards andwaiting rooms by 70 percent. (TBis a classical airborne infection,mainly spread when an infected

11

continued from page 10

12

person coughs, and the bacteriaresponsible for the lung disease aresprayed into the air, from wherethey are inhaled by others.)Although transmission of the dis-ease germs was not eliminated, onthe basis of the study findings, theresearchers were planning to installupper room UV lights in the chestclinic at St. Mary’s Hospital inLondon, the first such installationin the UK.

• In a presentation at the 2011 APICmeeting, researchers at HighlandHospital, a 260-bed communityteaching facility affiliated with theUniversity of Rochester MedicalCenter in New York, reported useof a portable UVGI device thatemployed mirrors to reflect UVCemissions around patient rooms.John Boyce, M.D., clinical profes-sor of medicine at Yale University,and William Rutala, Ph.D., direc-tor of the Statewide Project forInfection Control and Epidemiolo-gy at the University of North Car-olina, had, in a previous study,shown the device to be effectiveagainst C. diff. The Rochester hos-pital had 18 years’ worth of rigor-ous data on hospital- and commu-nity-acquired C. diff, and duringthe first quarter of 2009, experi-enced its highest rate of the infec-tion, 2.2 per 100 patient days. Thisrate amounted to 42 cases andthree deaths. At the time of thestudy, the group had already triedall of the SHEA Compendium pre-vention strategies but to no avail.For the study, the hospital firstclosed the unit with the highestincidence (11 cases against an

expected three cases, and twodeaths), and “terminally cleaned”each room with bleach. Then eachroom was cleaned again with aportable UVGI machine movedaround in a priority fashion basedon the incidence of C. diff. Eachtreatment lasted 45 to 60 minutes,depending on room size. Resultsshowed that in the three monthsfollowing the use of the UVGIequipment, the C. diff ratedropped to 16 per 1,000 patientdays. And in the following quarter,it dropped to 0.8—the lowest doc-umented rate in 10 prior quarters.The number of cases that aroseduring hospitalization droppedfrom 14 to eight after UV treat-ment. Despite the success, theteam acknowledged that successfulUVGI implementation required“intense coordination betweennursing, cleaning services, andadmitting,” and that special educa-tion and reassurance for patients,visitors, and health-care workerswere needed because of the ozone-like odor generated by the treat-ment. The team also concludedthat the UV replacement bulbs,while relatively cheap, had to bereplaced and cleaned frequently toensure they were intense enough tokill microbes. And it also empha-sized that “stringent safety meas-ures must be in place to protectpatients and health-care workersfrom inadvertently entering theroom during treatment withportable units.” The investigatorsprobably could not rule out thatthe bleach used in the primarycleaning muddied the results. Insum, they said, “Portable UV lightis not meant to be a stand-aloneintervention, but rather another

tool in our prevention tool belt.”

• Muskogee Community Hospital, arural, 45-bed facility in Oklahoma,installed a custom-designed Steril-Aire system to sterilize all seven ofits operating rooms and procedurerooms each night. The hospitalpresident, Mark Roberts, said thehospital bought the unit based onevidence from the use of portableUVGI systems, and used the lightsafter regular business hours foreight hours per room per day,admittedly without any clear senseabout whether they would work.Evidence that the lights were work-ing came later from a study by theOklahoma Hospital Association,which found zero HAIs in the hos-pital throughout a 21-month peri-od. Small hospitals in Buffalo, NY;Bucks County, PA; Florida; andOrangeburg County, SC, have alsoinstalled the units.

• In a study of factors affecting“upper room” or ceiling levelUVGI, a team of investigatorsfrom the Harvard School of PublicHealth’s Department of Environ-mental Health used a room-sizedsimulator to test the value of UVlamps against nebulized Serratiamarcescens, Bacillus subtilis spores,and vaccinia virus. They concludedthat the UV power level had astrong influence but was only fullyeffective in the presence of air mix-ing that produced vigorous verticalair currents. Countering the notionthat UVGI is a quick or easy fix forHAIs, the team said, “…upperroom UV installation is a complexsystem that requires careful inte-gration of UV luminaires, UVpower, and room ventilation

continued from page 11

13

arrangements.” In short, there is aneed for ideal controlled condi-tions, which are rarely present inhospitals.

• A 2002 study by researchers undercontract with the National Insti-tute of Occupational Safety andHealth, a division of the NationalInstitutes of Health, looked at theefficacy of UV irradiation in con-trolling the spread of TB. (Again,TB is a classic airborne infection,and thus an ideal candidate forHVAC&R UVGI treatment stud-ies.) Considered by many to be theonly truly controlled trial of UVGIin a physically realistic setting as of2010, this study was conducted byinvestigators from the University ofColorado, and led by Shelly Miller,a Ph.D. in mechanical engineering.Over a six-year period, Miller andher team re-created a hospital set-ting, using mannequins as patients,to test the value of UV light inreducing health-care workers’exposure to TB infection. Thestudy was designed to take intoaccount the impact of in-room dis-tribution of airborne TB bacteria,and the effects of room air circula-tion, ventilation, and humidity onUVGI’s ability to inactivate thebacteria. The study also looked atthe effects of air mixing at a varietyof different intensities. Theresearchers used new commerciallyavailable UVGI fixtures, consistingof five lamps—four mounted ineach corner of the room and a fifthin the center of the ceiling. Themannequins were heated to humanbody temperature to re-create oneof the subtle factors that influences

air movement in a room, andaffects the amount of bacteria thatcomes into a breathing zone.Results showed that increasing theirradiance level of UVGI lampsincreased effectiveness, and thatthe effects of UVGI were “doserelated,” meaning results varieddepending on light intensity. Theresearchers also found that highrelative humidity lowered effec-tiveness; and that when warm aircame in via ducts near the ceiling(as in winter), the warm air simplyrested on the cooler air below andUVGI worked “dramatically” lesswell. As with other studies, thisone also found that optimal UVGIresults are difficult to obtain in“real life” settings.

• In 2007, due to concerns amongorthopedic staff about unspecificskin and eye symptoms, officials atBrigham and Women’s Hospital inBoston asked NIOSH to reviewthe safety of UVGI lamps mountedin the ceilings of some operatingrooms. As a result of the review, thehospital ultimately moved itsorthopedic operating suite to anarea with laminar airflow, andstopped using UVGI for intraoper-ative infection control. Orthopedicsurgeries are often unusuallylengthy. NIOSH and other agen-cies have reported it is best to useother means of disinfection forsuch purposes.

Perhaps the best summary of theseesaw of evidence for and against thevalue of UVGI is found in a 2010report in the American Journal ofInfection Control in which researchersfrom the National Institutes of Healthreviewed a plethora of studies of

UVGI disinfection in health-carefacilities, some noted above. Thereview concluded that “the balance ofscientific evidence indicates thatUVGI should be considered as a dis-infection application in a health-caresetting only in conjunction with oth-er well-established elements, such asappropriate heating, ventilating, andair conditioning systems; dynamicremoval of contaminants from the air[i.e., HEPA and other filters]; andpreventive maintenance in combina-tion with thorough cleaning of thecare environment.” The authors wrotethat although UVGI is microbiocidal,it is not “ready for prime time” as aprimary intervention to kill or inacti-vate infectious micro-organisms;“rather it should be considered anadjunct.” Moreover, the NIH teamconcluded that factors such as the

continued from page 12 ▲

Results of one study showed that

increasing the irradiance level of UVGI lamps

increased effectiveness,and that the effects of UVGI were “doserelated,” meaning

results varied depending on light

intensity.

▼

14

design of facilities, the installationand operation of the HVAC system,and attention to traditional cleaningand disinfection are all confoundingfactors in measuring the impact ofUVGI and “must be assessed before ahealth-care facility can decide to relysolely on UVGI to meet indoor airquality requirements for health care”and certainly to reduce infectiontransmission. Finally, the team calledfor “more targeted and multiparame-ter studies” to evaluate the “efficacy,safety, and incremental benefit ofUVGI for mitigating reservoirs ofmicro-organisms and ultimately pre-venting cross transmission ofpathogens that led to HAIs.”

In a review of the promise and lim-itations of UVGI published in 2004 inthe journal Managing Infection Con-trol, David Shagott, an engineer andfounding president of AbatementTechnologies, lends industry supportto the NIH view, concluding thatUVGI “can complement …otherinfection-control measures,” addingprotection for isolation rooms, labs,morgues, and autopsy rooms. Andnotably, the CDC’s 2003 Guidelinesfor Environmental Infection Control inHealth Care Facilities state that “as asupplemental air cleaning measure,UVGI is effective in reducing thetransmission of airborne bacterial andviral infections in hospitals…[and] canbe placed in [air] ducts as an adjunctmeasure in HEPA filtration but…cannot replace the HEPA filter.”

Tellingly, many commercialexperts—even those who want to seebroader use of UVGI—are hard putto disagree, although they are morelikely to bring up the “catch-22,”which, they say, occurs when trying to

fulfill the demand for those “more tar-geted and multiparameter studies.”

One problem, Steril-Aire’s Scheiracknowledges, is that most of the test-ing done to prove the killing ability ofUVGI is done in the laboratory underideal conditions, and that it is virtual-ly impossible or prohibitively costly tofaithfully reproduce conditions thatreflect the infectious environment in agiven hospital on a day-to-day basis.

Another problem, he says, is that it’sdifficult to get access to all strains ofthe organisms companies want totest. (Think anthrax.) And a third isthat even if studies could replicate the“real world” of hospital air handling,outcomes based on “before and after”measurements of pathogen counts arecomplicated by hospitals’ reluctanceto share infection risk data, and their

simultaneous use of other disinfec-tion technologies and traps (likeHEPA filters, chemicals, hand wash-ing, and alcohol gels). Hospitals can’tstop using these evidence-basedcleaning protocols owing to ethicaland regulatory guidelines for patientand worker protection.

Understandably, many of theexperts interviewed say that hospitalswant peer-reviewed studies and published proof of UVGI’s addedvalue, and are reluctant to movetoward UVGI without such evi-dence, not least of all because of theexpense involved.

One satisfied customer is EarnieStandley, director of facilities manage-ment at Baltimore’s Mt. WashingtonPediatric Hospital, who was involvedin hiring Chris McCarthy and LeachWallace to install UVGI in a renova-tion for an infant unit at the hospital.

“We looked into evidence-basedfacility design and came across theavailable information on exposing cir-culating air to UV light’s short wavelength germicidal action,” says Stand-ley. “We have babies here withimmune suppression and at high riskof bacterial, viral, and fungal infec-tions, and wanted to go the extramile.” Before the renovation, the unithad “standard filtration with HEPAfilters, and he acknowledged there“were never any problems with that.”But with the renovation “there wasthe opportunity to try the new tech-nology,” although the hospital did notabandon HEPA. Currently, Mt.Washington uses both HEPA andUVGI, and as yet has no data onwhether infection rates or cultures ofvarious infectious agents will show areduction. “It will take a year or so toget those data,” says Standley. “We’rehoping UVGI will show reductions in

continued from page 13

▲

Understandably, many of the experts

interviewed say hospitals want peer-reviewed studies andpublished proof of

UVGI’s added value,and are reluctant tomove toward UVGI

without such evidence,not least of all because

of the expenseinvolved.

▼

15

HAIs, and we’re pleased that theUVGI involved was not much moreexpensive than HEPA.”

OTHER NOVEL TECHNOLOGIES

Although UVGI is the main focusof this Abell report, other relativelynew technologies are being investigat-ed and used. Chief among them ishydrogen peroxide vapor, or HPV.Hopkins’ Perl notes that HPV is reli-able for bacterial kills, and effectivefor all surfaces, but it takes one to twohours or more to work, and is rela-tively expensive.

Some hospitals in Maryland areusing HPV to treat equipment aftercontamination, but others are using itpreventively. Data show substantialreduction in contamination in the inci-dence of C. diff and VRE outbreaks.

Less high-tech novelties includeregular auditing of mattresses to keepcolonies of MRSA and C. diff at bay.Makary, the Hopkins surgeon, con-ducted a study showing that some-thing as simple as properly positioning“red bag” trash waste containers thatmake it easier for surgeons, nurses,and clean-up crews to put contaminat-ed waste in the right receptacle cansave big bucks in every major hospital.

Hospitals are also experimentingwith other tactics, including anti-microbial surface coatings, single-patient rooms, and emergency-department entrance alternatives forinfected patients designed to reducecross contamination. Motion-sensorroom lights and doorways not onlysave energy costs in hotels, but theyalso reduce infection transmission inhospitals, and according to a HealthTechnology Center study in 2007,

going green is trending upwardnationwide as a result. “The high costof energy and operations, coupledwith increasing environmental con-sciousness, has elevated the impor-tance of green design for health-carefacilities,” says Molly Coye, M.D.,CEO of Health Technology Center.

Hospitals are also increasinglyemphasizing green cleaning to notonly prevent infections, but to alsoincrease patient satisfaction, as manycleaning agents produce unintendedannoying or harmful effects on humanhealth. Disinfectant chemicals, in par-ticular, may increase asthma and skinproblems, and damage ecosystems,water sources, and plastic surfaces.The Center for Health Design andHealth Care Without Harm has part-nered with Healthier Hospitals Initia-tive, for example, to launch researchprojects at Dartmouth HitchcockMedical Center, Cleveland Clinic, andother institutions to test the use ofgreen cleaners with fewer harmfulingredients. Maryland has an activeHospitals for a Healthy Environmentinitiative based at the University ofMaryland School of Nursing. Just thepractice of pouring chemicals oncloths, instead of spraying them on,can reduce indoor air pollution. Archi-tects are even designing new hospitalsthat reduce horizontal surfaces, anduse more movable furniture to makecleaning easier.

There is also another technologyon the horizon for controlling themost intrepid hospital infections: rap-id genetic sequencing of deadly bacte-ria to track delayed or complex trans-mission routes and environmentalcontamination. A recent report in thejournal Science Translational Medicinedescribed one example at the ClinicalCenter of the National Institutes of

Health in Bethesda. A woman was admitted to the hos-

pital with Klebsiella pnemoniae, andalthough the strictest forms of infec-tion control were used to prevent itfrom spreading, 17 patients got it, andsix of them died. Infection-controlofficers were desperate to learn notonly how the bacteria escaped infec-tion controls, but also how to stop it.Using rapid genetic sequencing, theydetermined the genetic makeup of theoriginal bacterium in the woman andlearned that the chain of transmissionwas wiley, and that the germ managedto infect people in an undetectableway for weeks—so that in effect, it hada long latency period.

Not many places have the expert-ise and tools to perform rapidgenomic sequencing, but this caseclearly demonstrates that a) evenstrict infection-control standardsaren’t always enough to prevent con-tamination; b) infections can existwithout symptoms for long periodsof time, and can be undetectable evenwith the usual “culture swabs” fromthe throat or groin; and c) the bacte-ria was so environmentally stable thatit persisted in sink drains even afterdisinfection. In fact, the hospital hadto remove plumbing to get rid of the bacteria, and employ specializedtesting on every patient to rule outinfection transmission.

BARRIERS TO WIDER USE OF UVGI

As suggested by the researchreviews cited earlier, it is almost uni-versally the case that experts in engi-neering, infection prevention, andhospital risk management currentlyconsider UVGI as, at best, a supple-ment to HEPA filtration and othermore orthodox means of cleaning

continued from page 14

16

hospitals and reducing HAIs. But thesame experts, with often-equal una-nimity, agree that much can—andshould—be done to break down thebarriers to increased application ofUVGI technology.

The main barriers, they say, can becategorized as commercial, regulatory,engineering, practical, scientific, safe-ty, regulatory, cultural, and, for wantof a better term, philosophical. Eachcategory poses distinct challenges.

Commercial/Industrial Practicalities

UVGI engineering expert WilliamBahnfleth summarized this challengeby noting the relative absence ofUVGI industrywide standards thatsupport the application and use ofUVGI. Just as with television sets,automobiles, and other successfullymass-marketed appliances, UVGI sys-tems need some standardization toallow for confidence in, and con-sumer understanding of, the powerand design of UVGI components.Standardization is also needed forinstallation and retrofitting, equip-ment monitoring and replacementprotocols, maintenance procedures,and hospital staff training.

Companies, say Bahnfleth andKowalski, can compete effectively interms of quality, lamp life, and ease ofinstallation and maintenance, forexample, but as the industry standsnow, there is too much emphasis onthe proprietary aspect and notenough cooperation to allow formeaningful comparisons of technolo-gy, price, and value.

A few years ago, according toKowalski, the International UV AirTreatment Group tried to get all the

engineering, infection-control, anddesign and commercial stakeholderstogether to formulate standardizedguidelines, but efforts stalled for years,with companies suing each other overpatent infringements. There are somerelatively standardized guidelinesavailable, but they are not universallyaccepted, nor are they officially blessedby CDC, NIOSH, AIA, or ASHRAE.

Bahnfleth and his co-authors inthe 2008 review article were clear that“although application support forUVGI technologies is growing, andmany successful systems have beeninstalled, there are still no industrystandards for rating the effectivenessof UVGI devices and systems.” Citinga recent Environmental ProtectionAgency publication, Bahnfleth saidthe most important next steps inmoving UVGI along “are industrystandards to rate devices and installa-tions, as well as guidance for mainte-nance.” ASHRAE now has standingcommittees working to bring UVGImakers together for that purpose, butit will be some time, he says, beforethe industry agrees to testing stan-dards or design principles “applicableto all UVGI systems.” Until that time,say Bahnfleth and Kowalski, systemsshould be sized and designed usingthe best available information andguidance from ASHRAE handbooksto lend some measure of standardiza-tion to HVAC&R units.

For hospitals that want to try nov-el technologies for HAI reductionand greener cleaning, however, thatadvice falls short of what many needto part with their dollars and give upthe security of HEPA and otherproven technologies. In short, theyneed standardization and predictablereliability. Moreover, the absence ofthese standards creates significant

confusion not only within the UVGImarket sector, but also among com-peting technologies.

“There is an explosion of compa-nies, some green and with novel tech-nologies, offering new ways to preventHAIs, including UV lights,” saysPeter Pronovost, whose focus on evi-dence-based safety protocols and sys-tems is too often blurred by industrymarketing techniques. “I am pitchedfrequently by those promoting onesystem or another.” He recalls thatjust recently, “a company presentedinformation about a coating you painton hospital walls, or apply with mists,sprays. Another promotes anti-infec-tive polymers attached to spikes ornails that can be hammered into walls,a technology that the company saysdisinfects for 90 days and kills MRSA.Another one sells a coating for sur-faces that turns purple in the presenceof MRSA, and scrubs and exam roomcurtains with anti-infective technolo-gy built in. Why wouldn’t I want tobuy any of these? Because I have noidea which ones—even within a cate-gory—are best. No one knows. Thereare no reliable, up-to-date standardsor head-to-head comparisons, whichare needed when resources are notunlimited. There’s no question thatUV light kills germs, but controlledclinical trials with them are scarce. If Iget pitched 20 good ideas, which onedo I spend my nickel on?”

On the subject of standard designsand integrated systems, Pronovost isalmost apoplectic with frustration.“You know,” he says, “if an airlinewants to build a new plane, it doesn’torder the wings from a company thatdoesn’t talk to the company buildingthe fuselage or the engine or thehydraulics or the landing gear. The air-line goes to a systems integrator to not

continued from page 15

17

only assure the selection of the besttechnologies, but also to make sure allthe parts fit and work together smooth-ly with each plane’s design in order tooptimize safety and maintenance.”

Hospital engineers, facilities man-agers, infection-control specialists,and safety officers likely have neitherthe time nor the resources to test“each widget separately,” Pronovostsays, although he does think that aca-demic medical centers with broadexpertise in infection control and safe-ty could play a bigger role as “learninglabs” to test systems in a simulationcenter. “What we have here withUVGI, I think, is market failure.Companies need a place to test butalso to work with integrators. That’swhy hospitals may not be adoptingthese technologies more quickly.”

Chris McCarthy, the senior VP atLeach Wallace engineering firm,which has installed UVGI in Mary-land hospitals, understands the dilem-ma faced by hospitals that want to trynew technologies. “They have to see itto believe it,” he says, “and HEPA is asolid choice, especially if an institu-tion can’t afford custom or semi-cus-tom installations.” The costs anduncertainties, McCarthy says, make ithard for them to try UVGI, andfrankly, he adds, most of the prepack-aged HVAC equipment can’t accom-modate the UVGI lamps. “So unlessan institution can afford a custom-built HVAC system,” he says, “UVGIisn’t going to make it in. There is nostandard HVAC system I’ve seen thatcan accommodate existing lamps.”

Anatoly Gimburg, director offacilities at Hopkins, played a largerole in developing infection controland other safety design features for

the new $1.1 billion Johns HopkinsHospital buildings. He summed upthe concerns of his colleagues wellwhen he noted that “we looked at UVlight [for the new buildings], but theproblem is that other technologies arebetter known and standardized, andwith UV light, if something happensto the lamp or the power, you could

be unprotected for that time. Wedecided for air handling to stick withHEPA filtration.”

McCarthy agrees that as thingsstand now, UVGI is “one more thinghospitals can do, not a replacement.”He explains that, “chlorine tablets inair refrigeration drain pans work, too,and although with UVGI, nothingwill grow, institutions still for the

most part don’t see the benefit indoing the more expensive thing evenwhen maintenance crews like the ideaof an easier way to keep thingsmicrobe free. It’s an up-the-chainissue. Custom systems cost threetimes more than conventional air-handling systems.”

Regulatory Regulatory problems with UVGI

remain an issue, according to almosteveryone interviewed for this report.The CDC, for example, has become anotable target, criticized for being tooslow to put its investigatory power towork on behalf of UVGI and othernew technologies. So far, according toUVGI research engineer Kowalski,the CDC has only chosen to seriouslyexamine UVGI’s effect on TB control.“Eight different CDC guidelinesaddress UV in positive ways, butsometimes in negative ways,” he says.“The hope is that CDC, as a leadagency on infection control, wouldchampion more rigorous researchagainst other pathogens and UVGI,the way it did for TB. That wouldmove things along more quickly.”

Particularly during a recession, thecost of satisfying regulatory require-ments for new technologies is a seri-ous issue, but Scheir and others in theindustry are frustrated by the generalunwillingness of the health-careindustry, along with the NIH, to fundmore studies of UVGI’s potential.The bottom line is that “hospitals arevery conservative about infection con-trol,” according to Gimburg, “andalthough we test some technologies,federal and state regulations block ourability to easily swap out old tech-nologies for new. We need to gothrough many liability hoops andspend a lot of money and effort to

continued from page 16

▲

Particularly during a recession, the cost ofsatisfying regulatoryrequirements for new

technologies is a serious issue, but

Scheir and others inthe industry are frus-trated by the generalunwillingness of thehealth-care industry,along with the NIH,to fund more studiesof UVGI’s potential.

▼

18

prove we are not making city water orpatient safety worse. HEPA filters areincluded in many code regulationsand because UV light is not includedin those codes for hospitals, we can’tjustify it.”

Hopkins’ Trish Perl, who is alsothe former SHEA president, says,“UV light is reliable for bacterial kills,good for all surfaces, and relativelyquick, but there are huge cost and sus-tainability uncertainties, and a lack ofclinical trial data.” She adds that atHopkins, transmission of bugsthrough air handling is far less a wor-ry than what happens on surfaces andon walls, and UVGI is only effectivein such settings when in direct contactwith contaminated surfaces, with allthe attendant safety and operationalconcerns such irradiation brings withit. “It’s not that hospital epidemiologyand infection-control officers are dis-interested in UVC, but we must gowhere the biggest problems are for us.Transmission through air handling isfar less a worry in the big picture.Much more worry is what is happen-ing on surfaces.”

EngineeringKowalski, Bahnfleth, and other

engineers who have spent their profes-sional lifetimes working on improvingUVGI, agree that while the concept ofincorporating UV light-emitting systems into HVAC&R has been relatively well defined, many engineer-ing details required for installation andimplementation remain complicatedbecause of the high variability of eachhospital’s air-handling systems, building designs, geography, andpatient population.

Among the technical engineering

elements always in need of considera-tion for UVGI to work, says DavidShagott of Abatement Technologies, isthe distance between UVGI lampsand the pathogens that are their tar-gets: To kill pathogens, they must becaptured within a relatively close andclosed-in area, and those distancesvary among species. Other factorsinclude proper calculation of theintensity of the UVGI lamps andlength of exposure required in a par-ticular situation, which vary enor-mously from one product to another.

Mechanical engineers and build-ing designers also have concerns withthe complexities of both “upperroom” and in-duct fixtures. Theupper room units—which accordingto Shagott, look “like an upside-downfluorescent light fixture”—are sup-posed to irradiate the air at or near theceiling without exposing persons

below. But “they rely on consistent,measurable, and modifiable air cur-rents to bring the pathogens in closeenough proximity to the lamps to killthem,” he says. From an engineeringstandpoint, it is probably best toattach the units to HEPA filtration,but this can’t always be done withoutripping out, replacing, or expensivelyretrofitting HVAC&R systems. In-duct UVGI lamps installed inHVAC&R systems have their owndifficulties: They are often harder toinspect, service, or replace withoutdisturbing ceiling tiles or othermechanical parts.

In a 2001 article in EnvironmentalEngineering Policy, Christopher F.Green and Pasquale V. Scarpino, ofthe Department of Civil and Environ-mental Engineering at the Universityof Cincinnati, noted that the “effi-ciency of UVGI units depends largelyon other engineering controlsdesigned specifically for each site,”and that the opportunities for mis-matches and “leaks” in the systems areliterally endless.

“Although it is clear that UVGIcan be effective in test chambers,”according to Nicholas G. Reed of theU.S. Army Center for Health Promo-tion and Preventive Medicine in a2010 Public Health Reports, “engineer-ing specifications for a given roomapplication [of UVGI] remain elusiveand are currently based more on com-mon sense and historical practice thanon actual evidence.”

SafetyAs noted earlier, exposure to UV

radiation during disinfection continuesto pose challenges for hospitals. Withportable units, rooms can be cleared;however, in some institutions, patientrooms and ORs are at a premium and

continued from page 17

▲

In addition to thehealth hazards

already described,UVC radiation also

poses a threat to plastics, rubber, andinsulation aroundwiring and other

equipment because ofits ability to break

down chemical bonds.

▼

19

cannot always be taken out of circula-tion for treatment. During lamp main-tenance and replacement, exposure isalso a threat to maintenance crews whowork close to the units, and equipmentbreakdowns can occur.

In addition to the health hazardsalready described, UVC radiation alsoposes a threat to plastics, rubber, andinsulation around wiring and otherequipment because of its ability tobreak down chemical bonds.

Research and Scientific IssuesIn a review article in the June 2010

issue of the American Journal of Infec-tion Control, a blue ribbon team of spe-cialists and patient safety experts fromthe National Institutes of Health; theSt. Joseph Mercy Health System inAnn Arbor, MI; and EpidemiologyConsulting Services, wrote that “mostof the experimental data that led to thedevelopment of UVGI systems [andused for the reviews] were decades old.Aside from anecdotal observations, lit-tle information about the actual per-formance of these systems in hospitalrooms was available….”

The authors went on to say that,to date, most of the existing evidencewas collected “under simulated condi-tions that are generally more idealthan what is to be found in everydayoperations of hospitals.” AuthorsFarhad Memarzadeh, Russell Olm-stead, and Judene Bartley also notedthat even small air pressure differ-ences, induced by air temperaturechanges and mechanical fans, compli-cate the efficacy and efficiency ofUVGI and the movement of airbornepathogens in and out of the room,and around patients, caregivers, andvisitors. Moreover, depending on the

pathogen, survival times under vari-ous conditions—including outside airtemperatures and humidity—varyenormously, making the value ofUVGI “extremely series dependent.”

Further, they said, “tests to deter-mine the relative sensitivity of micro-organisms to UVGI are not standard-ized among laboratories and thus dif-ficult to rely upon.” Guidelines areneeded to determine the most practi-cal method for planning effectiveUVGI systems in a variety of roomsor areas and “many marketing claimssuggesting UVC systems…have notbeen substantiated…” against a vari-ety of germs.

Along with the scarcity of rigorous-ly controlled clinical trials of UVGI inrealistic hospital settings, scientists areseriously worried about the inability orunwillingness of hospitals to accurate-ly measure pathogen loads in varioushospital settings. In the absence ofsuch details—which bugs are mostprevalent where, which germs aremutating, and which are the biggestthreats in micro-environments—it’shard to know which technologies arebest, and when supplemental treat-ments such as UVGI might signifi-cantly contribute to HAI reduction.As Perl states, “if you don’t knowwhere you are, it’s hard to say whereyou want to go or how to get there.”

Martin Makary, Hopkins surgeonand author of Unaccountable: WhatHospitals Won’t Tell You, recently con-ducted a study suggesting that U.S.patients would be far better servicedby national standards for hospitalinfections tolerance, and that morepublicity about infection rates wouldboost a variety of efforts to reducethem, pressuring hospitals to conductmore rigorous measurement of theirown problems, and adopting or inten-

sifying existing technologies to reducethe prevalence of infection.

Perl, Scheir, and other infectiousdisease experts also report that moreresearch needs to be done on thecapacity of some bacterial cells toreactivate once exposed to visible lightafter UVGI treatment, as well as onwhat might be done to reduce therisks of allergic and hypersensitivityreactions to many microbes evenwhen they are killed and renderednoninfective by UVGI light. Theirdormant or dead shells contain anti-gens that, like the dead skin and furthat make up animal dander, can con-tinue to cause such reactions. Com-bining UVGI with HEPA filtrationtakes care of a lot of the problem, butalso begs the question as to whyHEPA filtration alone is not enoughin many hospital applications.

To be sure, progress is being madein both useful research and codifica-tion of knowledge. Wally Kowalskirecently published the book HospitalAirborne Infection Control, which tab-ulates microbe counts and evaluationsof suitable technologies for each of the20 traditional airborne infections aswell as the infections that in recentyears have been recognized to betransmitted and spread in the air, eventhough they are not classical airborneinfections such as measles and TB.Others in his field consider the com-pendium a tool that should make iteasier to match up infectious diseaserisks and evidence-based solutions.

Nevertheless, as Kowalski himselfsays, far more research is needed toconvince hospital epidemiologists andadministrators to embrace UVGI.“It’s easy,” Kowalski says, to show thatUV kills microbes in air, on surfaces,and in water, and that it reduces air-borne concentrations of microbes.

continued from page 18

“What’s hard is to demonstrate a sta-tistically significant reduction in dis-ease prevalence as a result. That hasbeen done in office buildings, but notyet in hospitals. CDC would have totake notice of a hospitalwide study ofair ducts, but no companies havedone this and no institutions have.”

RECOMMENDATIONS Sources interviewed for this report

acknowledge that breaking down thebarriers to wider use of UVGI willrequire resources, time, and coopera-tion within the UVGI industry, andbetween the industry, hospital andinfection-control interest groups, andregulators. As for a list of “prioritysteps” they would like to see taken, ortaken further, they mostly agreed onthe following:• Intensified efforts to achieve some

national standards for componentdesign, testing, and training withinthe industry, assisted by ASHRAEand other professional societies and organizations.

• Greater transparency about the

specifications of their technologyamong UVGI manufacturers tofacilitate competition with otherclean HAI-reducing technologiesand strategies.

• Coordination among industry andhealth-care experts to seek supportfrom the NIH, CDC, and NIOSHfor simulation studies and hospital-wide demonstration projects.

• Coordination of efforts to seekpublic and private organizationresearch grants to advance compar-ative effectiveness studies and fill ingaps in knowledge about optimalUVGI use.

• Performance of head-to-head stud-ies comparing various UVGIequipment, and comparing UVGIto other disinfection and steriliza-tion techniques.

• A commitment by UVGI expertsacross disciplines to develop pub-lic awareness and education pro-grams about the benefits and risksof UVGI.

• Wider information sharing amonghospitals and with the public ofhospital infection rates and effortsto monitor them.

• Sharper focus by the industry onthe “supplemental” value ofUVGI, as opposed to its “stand-alone” value.

• An industry commitment to fundand support rigorous research ofUVGI technology claims, submit-ted for peer review and publication.

• Commitment to conducting cost-effectiveness research.

• Increased focus on research thatnot only demonstrates microbialkills, but also demonstrates a directimpact of UVGI on reduced HAIrates, controlling for other con-founding factors such as tradition-al disinfection.

Whether or not the UVGI indus-try, hospitals, regulators, and agenciesact on these recommendations any-time soon, those who know the mostabout UVGI share the view that with-out such action, UVGI is unlikely tobecome a top choice among thosecharged with reducing HAIs.

20

continued from page 19

Joann Rodgers, M.S., an award-winning science journalist, directed Johns Hopkins Medicine’s media relations andpublic affairs division for 25 years, and now serves as a consultant there, and as a faculty scholar and senior com-munications adviser at the Johns Hopkins Berman Institute of Bioethics in Baltimore. A graduate of Boston Uni-versity and the Columbia University Graduate School of Journalism, she was the national science correspondentand columnist for the Hearst Newspapers for 18 years; is a board member and past president of the Council for theAdvancement of Science Writing; past president of the National Association of Science Writers; a Fellow of theAmerican Association for the Advancement of Science (AAAS); and a member of Sigma Xi, the Scientific ResearchSociety. The author of seven books, including Sex: A Natural History (Henry Holt and Company, NY) and Psy-chosurgery: Damaging the Brain to Save the Mind (HarperCollins, NY), she lectures and consults frequently aboutcrisis management and risk communications, strategic media relations, and science writing. She has contributedarticles on medicine, genetics, risk communications, and psychology for The New York Times Magazine, PsychologyToday, the Los Angeles Times, Ladies Home Journal, Redbook, Seventeen, Mosaic, and other publications. Her awardsinclude a Lasker Award for medical journalism. Her two grown sons and their families live in California.