Indoor Air Quality Protocols and Communication

1. Indoor Air Quality Protocols and Communication Phil Alexakos, MPH, REHS Chief of Environmental Health and Emergency Preparedness Manchester Health Department

2. Special Thanks To: • Jim Thomas, CIH, MPH • Rosemary Caron, Ph.D., MPH

3. Purpose • Establish guidelines and uniformity for conducting indoor air quality and mold related investigations in Manchester schools.

4. 5 Phases: • 1. Receipt of Complaint • 2. Data Gathering • 3. On Site Investigation • 4. Report • 5. Discuss Results

5. Phase 1: Receipt of Complaint • Role of Principal • Open Dialogue with Those Concerned

6. Phase 2: Data Gathering • Interviews (Limited) • Diaries (Limited) • Questionnaire (Expanded) • School Nurse Data • Data Analysis • Building Design Review (Floor Plans, HVAC)

7. Phase 3: On Site Investigation • Walk-through of Building • Grab Sampling of Basic IAQ Parameters • Additional Sampling as Indicated

8. Phase 4: Report • Provide History & Background Information • Include Findings and Non- findings • Include Recommendations

9. Phase 5: Discussions • Principal • Staff • Parents • Building Maintenance

10. Important Points • Rarely is There a Single, Clear Cause IAQ Problems. • Other Issues Can Mask or Compound IAQ Problems. • No Magic Test to Find IAQ Problems

11. Important Points • Communicate • Communicate • Communicate

12. Proactive Communication • Identify an indoor air quality coordinator • Staff can go to one person to seek information and/or share a concern • Anticipate possible triggers • Chain of Command

13. WHO?? • School Principal • School Nurse • Chief of Facilities • Person with the least seniority

14. Reactive Communication • Share valid information as soon as you can • Take each concern seriously • Provide updates to complainants and other affected parties • Pre-identify media spokesperson

15. Communication Best Practices • Respect • Listen • Update • Rumor Control • Final Report

16. Goal • To work collaboratively to assure that a building’s air quality is as good as possible.

17. Case Studies • Acute vs. Chronic

18. Unknown Illness in the School Setting ACUTE ISSUE

19. UH OH!!! • Call to EH Division from a School Nurse at 10:00 am • Multiple students (10) vomiting in the office • The school has 618 students, and 66 staff----Grades K-6 • EH dispatched to the scene

20. Possible Issues Considered • Common Food Source • School lunch • Common Event • class or activity • Indoor Air Quality Issue • chemical exposure • Unknown

21. Indoor Air • The school was surveyed for any unusually odors or chemicals being used • The EH Division used their IAQ equipment to help rule out this exposure • CO, CO2, VOC’s

22. Data Collection • A second EHS went to the school to assist with data collection • The following information was compiled: • Ill Student contact information • School Food Records • Attendance Records • Dismissal Records

23. Data Collection-2 • Map of school • Absentees per classroom (attack rates) • Lists of volunteers • Lists of substitute teachers • “Typical” absentee rate • “Typical” number of nurse send homes • “Typical” number of students vomiting

24. Data Collection-3 • School Health Supervisors called all of the other school to see if they were experiencing anything similar • No other school reported any elevated levels of GI illness • Note: This was pre-electronic surveillance

25. Incident Response Team • Was convened with representatives from all Divisions • EH, SH, CH, CD • Health Officer, School Nurse, State Health Department • Interventions were discussed • Don’t wait to act!

26. So Far... • Ruled out Common Food Source • Ruled out chemical exposure • Ruled out a common event • Person-to-person transmission is most likely

27. Environmental Cleaning • Called Contracted Custodial Company • Explained the nature of the illness • Targeted most affected rooms • Tables, chairs, bathrooms, nurse’s office, railings and door knobs • Extra staff to be allocated

28. Environmental Cleaning?? • School Nurse reported insufficient cleaning of the school • Vomit still on carpeting • Bathrooms not cleaned • Report of no extra extra staff • EH Supervisor to inspect on Saturday and Early AM Monday to ensure proper cleaning

29. Sample Collection • Two Stools were collected from Staff members that fell ill over the weekend on 3/29 • A meeting with school staff and a memo to parents went home on 3/29 • provided hand sanitizer to all rooms • One of the two samples was positive for norovirus

30. Conclusion • Not a common source • Sibling transmission documented • High number of students out on Monday • 20% were ill on Friday or siblings of them • Norovirus was confirmed • The illness presented with vomiting in children, but mostly diarrhea in adults • Self limiting illness 24-48 hr. duration

31. Lessons Learned • Poor cleaning probably helped to propagate the illness • The nurse is the best sentinel • STEMS corroborated our thoughts here but is still developmental (It is an important tool as well) Data issues • frequent flyers v. legitimate cases • kept teachers and staff informed

32. Lessons Learned -2 • Important to have access to all of the data we might need • contact, lunch, maps, baseline absentee, school event calendars • Communication to staff and parent s was probably too late (fear and rumors) • Principal was out ill • Lack of responsibility at school

33. Lessons Learned-3 • Cafeteria table cleaning duties were not well understood • Children should be discouraged from sharing popcorn • Good inter-divisional cooperation and support • Students, parents and faculty need to be reminded to NOT come to school when ill with vomiting, diarrhea (they should stay out for at least 24 hrs.)

34. Unknown Illness in the School Setting Chronic Issue

35. Details • Middle School • Built into the side of a large hill • Subterranean“Bomb Shelter” • Dirt floor, unventilated space

36. Data Collection • Symptom questionnaires (journals) • IAQ parameters via data logger • School Nurse student asthma data • Face-to-face interviews with teachers

37. Symptoms • Stuffiness • Burning eyes • Respiratory • Rash

38. What Did We Learn? • Air exchange was not in balance • Negative air • Bomb shelter was being entered • Humidity levels were >50 % • Multiple complainants on the floor, all abutting the Bomb shelter space

39. What Did We Do? • Restricted access to bomb shelter, all staff • Installed a mechanical vent with alarm in the bomb shelter space (negative air) • Adjusted balance in rooms to be positive

40. Added Wrinkle • Specific mold related sensitivity complaint • Indoor and Outdoor comparative sampling with no significant difference between the two

41. Final Steps • Communicate results • Establish a mechanism for any further complaints or issues

42. Questions & Answers