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Contents

OVERVIEW 5<s>6</s>

'''''Abbreviations''''' 9<s>8</s>

PART A – POLICY AND SERVICE CONTEXT 11<s>9</s>

Legislation, policies and international guidance 11<s>9</s>

1. LEGISLATIVE CONTEXT 11<s>9</s>

2. Further reference material and precedent<s>:</s> 11<s>9</s>

3. INFECTION PREVENTION AND CONTROL LEGISLATION 12<s>10</s>

4. BUILDING LEGISLATION 12<s>10</s>

5. SOUTH AFRICAN BUILDING PRACTICE POLICY AND GUIDELINES 12<s>10</s>

6. INTERNATIONAL DESIGN GUIDANCE 12<s>10</s>

Service Context 13<s>11</s>

PART B – PLANNING AND DESIGN 15<s>12</s>

1. INTRODUCTION 15<s>12</s>

2. LOCATION OF THE MORTUARY AND ACCESS ROUTES 16<s>13</s>

3. FACILITY CAPACITY 16<s>13</s>

4. SELECTING BODY STORAGE SYSTEMS 18<s>14</s>

5. FACILITY LAYOUT 18<s>15</s>

6. MORTUARY EQUIPMENT REQUIREMENTS 21<s>17</s>

7. MOVEMENT WITHIN A MORTUARY 22<s>18</s>

8. SERVICES REQUIRED 24<s>19</s>

9. BIOLOGICAL SAFETY 24<s>19</s>

10. FINISHES TO FLOORS AND WALLS 25<s>20</s>

11. AUTOPSY EQUIPMENT/FIXTURES 26<s>20</s>

12. VENTILATION 27<s>21</s>

13. AIR CONDITIONING 27<s>22</s>

14. REFRIGERATION EQUIPMENT DESIGN AND INSTALLATION 28<s>22</s>

15. SECURITY ARRANGEMENTS 28<s>22</s>

PART C – OPERATION 30<s>24</s>

1. OBJECTIVES 30<s>24</s>

2. HEALTH AND SAFETY 30<s>24</s>

3. MAINTENANCE 30<s>24</s>

PART D –USER ROOM REQUIREMENTS 32<s>32</s>

Room Requirement Sheets 32<s>32</s>

PART E – EXAMPLES AND CASE STUDIES 36<s>35</s>

Layout Examples 36<s>35</s>

1. EXAMPLE 1: SMALL MORTUARY ATTACHED TO HOSPITAL 38<s>36</s>

2. EXAMPLE 2: LARGE MORTUARY WITH AUTOPSY FACILITIES 39<s>37</s>

3. EXAMPLE 3: LARGE MORTUARY WITH AUTOPSY FACILITIES 43<s>40</s>

BIBLIOGRAPHY 46<s>42</s>

'''Table of Figures'''

Figure 1 Adjacency Diagram 1<s>16</s>

Figure 2: Access and Movement in a mortuary 1<s>18</s>

Figure 3 Example 1: Layout 1<s>35</s>

Figure 4 Example 1: Zoning & Access 1<s>36</s>

Figure 5 Example 2: Layout 1<s>38</s>

Figure 6 Example 2: Zoning and Access 1<s>39</s>

Figure 7 Example 3: Layout 1<s>40</s>

'''Table of Tables'''

Table 1 : IUSS Reference documents 8<s>7</s>

Table 2 Service Requirements 13<s>11</s>

Table 3 Accommodation Schedule 32<s>25</s>

TABLE 4 ROOM SERVICES SHEET 33<s>26</s>

TABLE 5 ROOM FINISHES 34<s>27</s>

''Version Control''
{| class="wikitable"
|''Template''
|''January 2013''
|''Tobias van Reenen''
|-
|''Discussion Draft 1''
|''February 2013''
|''Steve Fourie''
|-
|''Discussion Draft 5''
|''March 2013''
|''Steve Fourie''
|-
|''Discussion Draft 6''
|''May 2013''
|''Steve Fourie''
|-
|''Development Draft 1''
|''August 2013''
|''Tobias van Reenen''
|-
|''Development Draft 3.1''
|''February 2014''
|''Tobias van Reenen''
|-
|''Development Draft 3.1''
|''February 2014''
|''Prof J Vellema''
|}

Page Break

=='''OVERVIEW'''==

This document outlines the policy and service context and attempts to illustrate the desired planning principles and design considerations for mortuary services.

*''Part A'' outlines the South African legislation, policies and international guidance reference documents and the service context with respect to mortuary services;
*''Part B'' Planning and design;
*''Part C'' operation;
*''Part D'' user room requirements; and
*''Part E'' provides case studies.

Parts D and E are intended to demonstrate how the principles prescribed in Part A, B, and C can be applied in worked examples. Part D, if used directly, are deemed<s>-</s> to<s>-</s> satisfy the principles developed in Part B, but are not the only acceptable solutions.

Case studies (Part E) provide illustrative worked solutions and should not be adopted without appropriate contextual adaptation.

While this document outlines design requirements and acceptance criteria which have an impact on clinical services, these requirements are prescribed within the framework of the entire IUSS set of guidance documents and cannot be viewed in isolation. The following documents should be complied with, together with this document:

*IUSS: Regulations
*IUSS: Project Planning and Briefing
*IUSS: Environment and Sustainability
*IUSS: Hospital Design Principles
*IUSS: Infection Prevention and Control

Page Break

The following table identifies additional IUSS guideline documents which are recommended for reading in conjunction with this guideline.

==='''Table 1 : IUSS Reference documents'''===
{| class="wikitable"
|

'''CLINICAL'''

'''SERVICES'''
 
|Essential
|Recommended
|'''SUPPORT'''

'''SERVICES'''
|Essential
|Recommended
|'''HEALTHCARE ENVIRONMENT/ CROSSCUTTING ISSUES'''
|Essential
|Recommended
|'''PROCUREMENT'''

'''& OPERATION'''
|Essential
|Recommended
|-
|Adult Inpatient Services
|
|X
 
|Administration and Related Services
|
|
|Generic Room Requirements
|
|
|Integrated Infrastructure Planning
|
|
|-
|Clinical and Specialised Diagnostic Laboratory Guidelines
|
|X
|General Hospital Support Services
|
|X
|Hospital Design Principles
|
|
|Briefing Manual
|
|X
|-
|Mental Health
|
|
|Catering Services for Hospitals
|
|
|Building Engineering Services
|X
|
|Space Guidelines
|
|
|-
|Adult Critical Care
|
|
|Laundry and Linen Department
|
|X
|Environment and Sustainability
|
|
|Cost Guidelines
|
|
|-
|Emergency Centres
|
|
|Hospital Mortuary Services
|
|
|Materials and Finishes
|X
|
|Procurement
|
|
|-
|Maternity Care Facilities
|
|
|Nursing Education Institutions
|
|
|Future Healthcare Environments
|
|X
|Commissioning Health Facilities
|X
|
|-
|Adult Oncology Facilities
|
|
|Health Facility Residential
|
|
|Healthcare Technology
|
|
|Maintenance
|X
|
|-
|Outpatient Facilities
|
|X
|Central Sterile Service Department
|
|
|Inclusive Environments
|
|
|Decommissioning
|X
|
|-
|Paediatrics and Neonatal Facilities
|
|
|Training and Resource Centre
|
|X
|Infection Preventive Control
|X
|
|Capacity Development
|
|
|-
|Pharmacy
|
|
|Waste Disposal
|
|X
|Health Informatics
|
|
|
|
|
|-
|Primary Health Care Clinics and CHCs
|
|
|
|
|
|Regulations
|
|
|
|
|
|-
|Diagnostic Radiology
|
|
|
|
|
|
|
|
|
|
|
|-
|Adult Physical Rehabilitation
|
|
|
|
|
|
|
|
|
|
|
|-
|Sub-acute services
|
|
|
|
|
|
|
|
|
|
|
|-
|Facilities for Surgical Procedures
|
|
|
|
|
|
|
|
|
|
|
|-
|TB Services
|
|
|
|
|
|
|
|
|
|
|
|}

====='''''Abbreviations'''''=====
{| class="wikitable"
|ACH
|Air changes per hour
|-
|ASHRAE
|American Society of Heating, Refrigerating, and Air-Conditioning Engineers
|-
|BMS
|Building Management System
|-
|BSL
|Biological safety level
|-
|CDC
|Centers for Disease Control (USA)
|-
|CSIR
|Council for Scientific and Industrial Research
|-
|FD
|Floor drain
|-
|FPS
|Forensic Pathology Service
|-
|HVAC
|Heating Ventilation Air Conditioning
|-
|HBA
|Hazardous biological agents
|-
|HCS
|Hazardous chemical substances
|-
|HEPA
|High efficiency particulate air filters
|-
|IPC
|Infection prevention and control
|-
|ISO
|International Standards Organisation
|-
|MDR TB
|Multi-drug resistant TB
|-
|NDoH
|National Department of Health
|-
|NBR
|National Building Regulations
|-
|<s>NDoH</s>
|<s>National Department of Health</s>
|-
|NHS
|National Health Service (UK health service)
|-
|NIOSH
|National Institute of Occupational Safety and Health (US agency)
|-
|O&M
|Operating and Maintenance (manual)
|-
|OHS
|Occupational health and safety
|-
|OQ
|Operational qualification
|-
|PGWCDoH
|Provincial Government Western Cape Department of Health
|-
|PPE
|Personal protective equipment
|-
|PQ
|Performance qualification
|-
|RDS
|Room data sheets
|-
|RH
|Relative humidity
|-
|SABS
|South African Bureau of Standards
|-
|SAO
|Senior Administrative Officer
|-
|SAPS
|South African Police Service
|-
|SI
|<s>Le Systeme International d' Unites</s> Le Système International d’Unités
|-
|SOP
|Standard Operating Procedures
|-
|SS
|Stainless steel
|-
|TB
|Tuberculosis
|-
|WC
|Toilet
|-
|WHB
|Wash-hand basin
|-
|WHO
|World Health Organisation
|-
|XDR TB
|Extreme (or extensively) <s>-</s>drug- resistant TB
|-
|
|
|-
|
|
|-
|
|
|}

=PART A – Policy and service context =

=====Legislation, policies and international guidance=====

===1. LEGISLATIVE CONTEXT===
The following documents, as amended (though not an exhaustive list) pertain and contain an additional resource of information which would supplement and provide the basis of a design brief. A finer sense of standard operating procedures and legislative context is likely to inform and enhance the design process, so the professional teams are encouraged to use these as an additional resource:
 

*Inquest Act<s>,</s> 58, 1959
*National Health Act<s>,</s> 61, 2003
*Government Notice R363, 2013 [Regulations relating to the management of human remains]
*Government Notice R178, 2012 [Regulations relating to the registration of microbiological laboratories and the acquisition, importation, handling, maintenance and supply of human pathogens]

*Health Professions Amendment Act, 29, 2007
*Criminal Procedures Act<s>,</s> 51, 1977
*Births and Deaths Registration Act<s>,</s> 51, 1992
*National Environmental Management: Waste Act<s>,</s> 59, 2008
*National Archives of South Africa Act<s>,</s> 42, 1996

*Regulations regarding the Rendering of Forensic Pathology Service, ''Government Gazette'' No 30075. No R636, 20 July 2007
*Space Planning Norms and Standards for Office Accommodation used by Organs of State, ''Government Gazette'' No 27985. No 1665, 2 Sept 2005
*Western Cape Health Care Waste Management Draft Bill
*Municipal by<s>-</s>laws, as applicable
*National Code of Guidelines for Forensic Pathology Practice in South Africa, 20 Aug 2007

*Standard Operating Procedures, Forensic Pathology Service, PGWCDoH, 2006
*Biosafety in Microbiological and Biomedical Laboratories, U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention and National Institutes of Health, Fifth Edition, <s>2007</s> US Government Printing Office, Washington: 2007

 

====2. Further reference material and precedent<s>:</s>====

*Standard specification for air-conditioning and ventilation systems, Western Cape Department of Public Works, 1998
*Fire security: a guide for architects, Western Cape Department of Public Works, 1998
*Standard electrical specification, South African Department of Public Works, 2005
*Facilities for mortuary and post-mortem room services, NHS Estates, 2001, ISBN 0-11-322000-00
*Part B – Health facility briefing and planning, Australasian Health Facilities Guidelines, 2007

*CKS 336: 2013 Mortuary Trolleys - SABS

====3. INFECTION PREVENTION AND CONTROL LEGISLATION====
The National Infection Prevention and Control Policy and Strategy document makes specific reference to certain Acts and their relevant regulations, which bear relevance to the development and implementation of these health facility guidelines. These are:

*The South African Constitution, 1996 [Sections 2, 24, 27, 36 and 39], as amended
*The Occupational Health and Safety Act of 1993, Act No 85 of 1993 [Section 8(1)]

*Government notice R1390 of 27 December 2001 [Hazardous Biological Agents Regulation] as promulgated under Section 43 of the Occupational Health and Safety Act of 1993
*Government notice R908 of 27 June 2003 [Hazard Analysis Critical Control Point Regulation] as promulgated under Section 15(1) of the Foodstuffs, Cosmetic and Disinfectants Act of 1972
*The Environmental Conservation Act of 1989, Act No 73 of 1989
*The Foodstuffs, Cosmetic and Disinfectants Act of 1972, Act No 45 of 1972 

====4. BUILDING LEGISLATION====
The following legislation and regulations impact and provide guidance on the provision and design of health care facilities as above:

*The National Environmental Management Act 107 of 1998, as amended
*Building regulations and Building Standards Act 103 of 1977, as amended
*National Building Regulations; SANS 10400:2010, Code of Practice for the Application of the National Building Regulations

*Promotion of Equality and Prevention of Unfair Discrimination Act No 4 of 2000
*General Procedures and Loadings adopted in the Design of Buildings, SABS 0160, 1993
*Structural Use of Concrete Design, SABS 0100-1, 1992
*Structural Use of Concrete – Materials and Execution of Work, SABS 0100-2, 1992
*Specification for Civil Engineering Construction SABS 1200 

===5. SOUTH AFRICAN BUILDING PRACTICE POLICY AND GUIDELINES===

*R158 of 1980 regulations pertaining to Private Hospitals and Unattached Operating Theatres – R198
*Good Pharmacy Practice, Board Notice 129 of 2004, as amended [see Chapter 1].

===6. INTERNATIONAL DESIGN GUIDANCE===

*ASHRAE Standard 52.2, “Method of Testing General Ventilation Air-Cleaning Devices for Removal Efficiency by Particle Size”, 1992, 1999b
*ASHRAE Standard 62, “Ventilation for Acceptable Indoor Air Quality”, 1989
*ASHRAE. “HVAC Design Manual for Hospitals and Clinics, 2003”, 1989
*CIBSE Applications Manual AM10:1997 “Natural Ventilation in Non-Domestic Buildings”, 1998
*CIBSE Applications Manual AM13:2000 “Mixed Mode Ventilation,” 2000

*ASHRAE Standard 170, “Ventilation of Health Care Facilities”, 2008
*QASA. “Know Your Rights” [Accessibility & the Built Environment]
*Department of Health and Human Services. “Environmental Control for Tuberculosis: Basic Upper-Room Ultraviolet Germicidal Irradiation - Guidelines for Healthcare Settings”, 2009
*WHO. “WHO Policy on TB Infection Control in Health-Care Facilities, Congregate Settings and Households”, 2009

Guidance has also been provided by AIA (USA), NHS (UK), and Australian Health Facility Guidelines on Healthcare Building Design. Additional references can be sourced from www.tb-ipcp.co.za

=====Service Context =====

The following table gives an indication of the service requirements for mortuaries within different types of public hospitals.

======Table 2: Service Requirements======
{| class="wikitable"
|'''Service'''
|'''District'''
|'''Regional'''
|'''Tertiary'''
|'''Central'''
|'''Specialised'''
|-
|Small (beds)
|50-150
|Min 300
|Min 400
|
|
|-
|Medium (beds)
|150-300
|
|
|
|
|-
|Large (beds)
|300-600
|Max 800
|Max 800
|Max 1200
|Max 600
|-
|Training
|Where practical
|Where practical
|Optional
|Yes. Attached to medical school
|
|-
|Conduct research
|
|
|
|Yes
|
|-
|'''Mortuary'''
|
|
|
|
|
|-
|Short-term stay (2˚C)
|Yes
|Yes
|Yes
|Yes
|
|-
|Long-term stay (-15˚C)
|Yes
|Yes
|Yes
|Yes
|
|-
|Autopsies (20°C -21°C)
|Yes
|Yes
|Yes
|Yes
|Yes
|}

For the determination of capacity requirements of mortuaries refer to the recommendations further on in this document.

This guidance document relates to mortuaries located within and serving hospitals, with respect to persons that die due to natural causes in that hospital. This document excludes mortuaries <s>exclusively</s> dealing exclusively with cases that require medico-legal investigation of deaths from unnatural causes.

Post mortems conducted in hospital mortuaries should be limited to conducting investigations and procedures where no medico-legal investigation is required and death from natural causes is suspected.

Hospital deaths from natural causes and those suspected to be of unnatural cases should not be managed in the same facility unless the hospital mortuary is equipped to comply with the specific legal requirements as <s>it</s> they relate<s>s</s> to the chain of evidence, etc. The requirements for forensic- pathology service mortuaries are not exhaustively detailed in this document.

It is also noted that some hospitals may opt to contract out the removal and storage of decedents to private undertakers and these hospitals may <s>only</s> require only the minimum in terms of refrigerated body storage.

=PART B – Planning and Design =

===1. INTRODUCTION===

#All state- run mortuary facilities fall within the domain of the Department of Health, both National and Provincial;<s>,</s> and in an effort to provide engineers and architects who are required to either design new facilities or upgrade existing facilities, this document provides the minimum standards necessary to comply with existing legislation.
#This document will provide designers of this type of facility with guidelines as to what is required in terms of the following:

*Type of service and package of care being provided
*Mortality rate
*Access and egress
*Discreet management of human remains

*Size and dimensions of the actual facility
*Positioning of mortuaries within hospitals
*Finishes of surfaces in these facilities
*Water- supply requirements
*Drainage requirements

*Electrical supply and lighting requirements
*Installation requirements for equipment and services
*Body-storage requirements
*Body-handling facilities
*Body-holding areas

*Body-viewing area
*Autopsy equipment (tables)
*Air conditioning and ventilation requirements (for infection and indoor air quality control)
*Security of the facility

#In addition to the items listed above, it is also necessary to consider the needs of visitors to these facilities, particularly those wishing to, or who are required to, identify bodies. In line with this it is also necessary to take the handling of bodies into consideration as it pertains to issues of patient dignity.
#Forensic pathology mortuaries are not <s>considered</s> exhaustively described in this document, although the majority of mortuaries do have basic facilities for general autopsies that are not necessarily medico-legal in nature. A forensic pathology mortuary has laboratory facilities attached that are outside the scope of regular mortuaries found in hospitals and at police stations. It should be noted that there are a number of principles that hold true for both hospital and forensic pathology mortuaries.
#Compliance with the requirements of the Occupational Health and Safety Act (Act 85 of 1993 as amended) are to be complied with at all times during the design of a mortuary.

 

===2. LOCATION OF THE MORTUARY AND ACCESS ROUTES===

#The position of the mortuary in a hospital should be such that the mortuary is easily accessible to mortuary staff and related service providers without presenting either aesthetic, emotional or ethical problems for unrelated hospital staff, patients or visitors. Visitors to the mortuary, however, should be provided with clear and direct access to the mortuary upon arrival at the hospital, without having to travel unnecessarily through hospital departments.
#Where bodies are moved into or out of the mortuary, they should not be moved through general public-access areas. Appropriate routes would include technical service or goods corridors and through the hospital’s support services yard.
#Special considerations should be given to plans for contingency access to the mortuary in the event of case- load surges, which may <s>be</s> result from disasters.
#Bodies should not be held for any period in any locations between the body- holding rooms within clinical areas and the mortuary.
#Where a mortuary unit is used jointly between the hospital and the local authority it is beneficial for the mortuary to be in a building separate from the main hospital building.
#The delivery of bodies to the mortuary and their subsequent removal from the facility is to be such that it is carried out in a manner that is not visible to the general public, preferably in a covered and enclosed area.
#While siting and access are important aspects when locating a mortuary, it is also important to provide the mortuary with pleasant surroundings in order to promote the dignity of those working in or visiting the mortuary. 

===3. FACILITY CAPACITY===

#The layout and size of a mortuary is largely determined by the number of bodies stored and whether body storage needs to be in cabinets or in refrigerated rooms.
#In order to determine the storage capacity of a hospital mortuary it is recommended that historical data, where available, should be used. In the South African context it is suggested that a storage capacity of between 5 and 10 bodies per 100 beds should be used. This varies with the rural or urban location of the facility. This capacity should not take into account the need to store bodies from deaths which are not hospital related, typically motor-vehicle accident deaths and deaths from criminal activity. Requirements for contingency storage capacity related to disaster management should be considered.
#The body storage capacity required can be estimated on the basis of the number of deaths per year in the hospital, the length of time of holding and the required body store occupancy rate. The number of body trays can be calculated from Equation 1<s>Equation 1</s> below.

-Equation 1

Where:

BT = Number of body trays

D = Number of deaths per year requiring body trays

S = Average length of stay (in days)

R = Required body tray occupancy rate

[Text Box]

#The estimated storage capacity for bodies in a mortuary could be confounded by a number of local factors, such as:

*Mortality rate from natural causes.
*Mortality rate from infectious disease. (Highly contagious disease deaths require special storage facilities.)

#Where the hospital is expected to place the body in cold storage until collection by forensic pathology services the following additional factors should be considered:

*Mortality rate from foul play.
*Mortality rate from traffic incidents.

 

===4. SELECTING BODY-STORAGE SYSTEMS===

#Body-storage systems are principally divided into refrigerated rooms or body cabinets. Differences within these system types occur where specific temperatures or sizes are required based on risk, need and capacity requirements.
#Where a system of functionally separate body cabinets is selected, this system would have an inherent redundancy against failure, as the failure of a single unit would not necessarily imply a system failure. In contrast, a refrigerated room would require less maintenance and would have a lower frequency of failure; however a single component failure could be critical if standby condensing units are not installed. For this reason, multiple- cabinet systems are recommended for areas where expected maintenance response times would negatively affect the mortuary’s operations.
#It is possible to have a requirement for a mixture of refrigerated rooms and body cabinets. This could be affected by local cultural requirements such as for families <s>which</s> who object to bodies sharing storage space, the case load of the facility or the case profile.
#Where there is a requirement for the long-term storage of bodies, these are to be kept at a lower temperature than would be the case in a refrigerated room. In this instance separate body cabinets are required. Long- term storage of bodies is most often required when an indigent person dies and difficulty is experienced in locating the next of kin, as the person cannot legally be buried until this process has been completed.
#In general, smaller facilities rely on body cabinets for the storage as these facilities do not have the space or the need for the large-scale storage of bodies, <s>and they do not</s>they would not appreciate the functional flexibility offered by these systems. By rule of thumb, any facility that has the requirement to store <s>less</s> fewer than 12 bodies at any given time should use body cabinets. This <s>provides</s> gives the option of providing both short- and long-term storage with the smallest facility and equipment footprint.
#Bodies suspected of having succumbed to a highly contagious and dangerous disease require special treatment. These should be stored in such a manner that they do not present a hazard to personnel working in the mortuary. Typically these bodies should be stored at the same temperature<s>s</s> <s>the same</s> as <s>for</s> long- stay bodies, e.g. -15˚C, and should be placed in hermetically sealed plastic body-bags.
#Provision for the secure cold storage of body parts should <s>also</s> be provided. 

=== 5. FACILITY LAYOUT ===

# As mentioned, the layout and size of a mortuary is going to be largely determined by case load and whether storage is in cabinets or refrigerated rooms. It is acceptable to have a mixture of refrigerated rooms and body cabinets.
# In a mortuary facility there are a number of separate areas that need to be considered other than the body- storage areas. These include:
# '''Reception area''' for members of the public who are required to visit the mortuary on official business – typically to identify bodies or to pay their last respects to a deceased person.
# '''Ablution areas''' for staff. Where unisex ablutions are provided it is recommended that <s>the</s> no urinal is provided.
# <s>'''Visitor’s'''</s> '''Visitors’ admin space''' close to the reception area, where any admin or official business related to the identifying of a body can be completed.
# '''Staff admin space''' close to the point where a body is delivered to the mortuary, so that pertinent documentation can be completed – both with respect to the delivery of the body, as well as when the body is released from the mortuary again.
# '''Office space''' for pathologists to write up reports <s>for</s> in instances where this could be required. This is dependent on the size of the mortuary as small facilities would not require a separate room(s) for this function.
# '''Waiting''' and circulation areas for visitors to the mortuary.
# '''Viewing room,''' from where a body can be viewed through a curtained glass window between this space and the body- display room.
# '''Body- display''' room, where a body is placed for identification purposes. There is to be access to this area via a lockable door to the viewing room <s>for</s> in instances where it is necessary for non-mortuary personnel to have direct access to a body in the viewing room. There is to be access to this room from the body- storage area to allow bodies to be brought in for display purposes.
# '''Body preparation''' area, where a body that is delivered to the mortuary needs to be attended to prior to it being placed in the viewing room.
# '''Shower facilities''' (staff)
# '''Changing room''' (staff)
# '''Storage space''' for equipment and clothing that is worn in the body-preparation and autopsy spaces.
# '''Body-storage''' facility (cold room or refrigerated cabinets), depending on the length of time that bodies are expected to be kept in the facility.
# '''Autopsy facility,''' where the cause of death can be determined. This facility will differ from mortuary to mortuary, depending on whether forensic or standard medical autopsies to determine the cause of death are conducted.

[GroupDrawing]
 

# Figure 1<s>Figure 1</s> is an example of an adjacency diagram for a typical mortuary. In this instance the proximity also relates to visual and physical access. It is also understood that not all mortuaries would require all of the spaces indicated in this diagram, and that some of the spaces shown as being '''''immediately adjacent''''' could be included as a single area if functionality and privacy considerations permit it.
# There remains abundant scope for variations in the planning of the layouts making up the mortuary. and the hospital architect should consult with all stakeholders to arrive at an ideal solution.
# When developing the facility layout, careful consideration should be given to the routes through the facility of staff, bodies and visitors. These routes should overlap as little as possible and there should never be a common entrance for bodies and staff or visitors.
# The room requirement sheets are presented in ''PART D – User Room Requirements<s>PART D –User Room Requirements</s>''of this document.
# Storage space for body lifts must be provided.
# Suitable sluicing facilities are required to be able to clean equipment and fabrics after completion of any work in the mortuary facility.

 

=== 6. MORTUARY EQUIPMENT REQUIREMENTS ===

# Equipment for storage and transportation of bodies should meet environmental hygiene standards.
# For mortuary trolley design and supply, the SABS published standard '''''CKS336:2013 Mortuary Trolleys''''' is recommended. It should be noted that this is not a normative South African National Standard, and individual requirements may differ.
# '''Body-cabinet''' selection and installation requires the following considerations:
# Three-level body cabinets could be selected which have a single door to give access to all of the body trays, for instances where separation between bodies is required. Alternatively, cabinets that provide a single door for access to all the body trays are acceptable.
# It is critical that bariatric (obese) bodies are catered for in each cabinet. The lowest-level tray should be designed for this purpose.
# Special consideration is to be given to the provision of capacity for storage of juvenile and infant decedents. The handling of these bodies is an especially sensitive and emotive issue, and separate storage in dedicated cabinets is recommended.
# Body lifts must be supplied to facilitate the loading of bodies into and removal of bodies from the cabinets. Body lifts help to preserve dignity when handling bodies, while at the same time making it easier and safer for mortuary personnel to handle bodies.
# A clear space must be provided in front of the body cabinets to allow for the placing of a corpse into the cabinets. It is recommended that there be at least a 3m clearance between the front of the cabinet and any fixed structure. This is to accommodate whatever means of conveyance is used to transport a corpse to ?? and then load it into the cabinet.
# Due to the vast array of cabinets available on the market and the lack of an appropriate national standard, it is not yet possible to prescribe sizes for refrigerated cabinets in this guide.
# The required cabinet size is fundamental when designing a mortuary. Where space is not too limited and there are no indications that there may be cultural concerns relating to the storage of bodies together in a cold room, it is recommended that cold rooms be used. Cold rooms offer space savings when compared to cabinets.
# A temperature gauge must be installed close to the door of the facility to indicate the storage-space temperature. This gauge should have an alarm system connected to it to give a warning should there be an unacceptable rise in temperature in the storage space. Typically, if the temperature should rise more than 2˚C above the set temperature, an alarm should be activated at a point that is manned at all times.
# Body cabinets and refrigerated rooms must be supplied with electrical power from the hospital’s essential services electrical supply.
# A slop hopper is to be provided to allow for the cleaning of the body preparation and autopsy areas, in particular after the completion of any work carried out in these areas.
# To allow for the rinsing of body parts and organs, during an autopsy procedure it is important that suitable basins be provided in close proximity to <s>the</s>a downdraft autopsy table.
# Where there is transition between “clean” and “dirty” areas, provision is to be made to allow for the cleaning of footwear in a “transitional” area. This helps prevent the transport of contaminants from dirty areas.

 

=== 7. MOVEMENT WITHIN A MORTUARY ===

# Movement of members of the public visiting the mortuary is to be restricted such that they do not have access to the body- preparation or autopsy areas. (Figure 2<s>Figure 2</s>)
# The facility must be available within the mortuary where body identification can be conducted in a private and dignified manner. This viewing area should consist of a body- display or layout room with an adjacent viewing room, where the body can be viewed through a curtained shatter-proof glass window.
# The requirement for a viewing and identification area also pertains to hospitals which outsource their mortuary services.
# The viewing room and visitors’ admin rooms should be designed such that counselling can be conducted in a pleasant environment for bereaved persons.
# The design of the viewing facility should allow <s>for</s> adequate space for persons to view a body in a dignified manner.
# Direct access to the body- layout room from the viewing room is to be provided via a lockable door, to allow visitors access to the body.
# Ablution facilities are to be available to members of the public who are required to visit the mortuary complex.
# [GroupDrawing]Where a dedicated room, as described above, cannot be allocated for placing a body for viewing purposes, the persons who are viewing a body should be given a private space for viewing the body through a curtained shatter-proof glass window, as a minimum.
# Adequate facilities to accommodate at least 7 visitors are to be provided.
# Staff access to the mortuary facility is to be separate from the general public. (Figure 2)
# Mortuary staff change rooms should be provided with secure lockers for storage of street garments, lab coats, personal protective equipment and valuables. <s>Street garments and lab garments</s>
# Mortuary staff may have completely separate ablution facilities from those used by the general public requiring access to the mortuary facility.
# In a free- standing mortuary building the delivery to and removal of bodies from the facility may be via the same access point to the building.
# A mortuary that forms an integral part of a hospital will require separate routes for receiving bodies and the subsequent removal thereof.
# In the unusual event that a body arrives from outside <s>of</s> the hospital, the normal route of removal should be used for receipt of the body.
# A clear distinction is to be made between “clean”,” “dirty” / “wet” and “transitional” areas. This is best achieved by creating a physical “RED LINE” on the floor indicating the separation of these areas, with “yellow lines” used to demarcate “transitional” areas. Receptacles for the collections of dirty clothing, etc, must be made available at the transition area from <s>a</s> dirty to clean areas and in change rooms.
# A well-drained facility for washing <s>of</s> vehicles which have been contaminated with decomposed bodies or <s>bodily</s> body fluids should be provided in an enclosed area, near to the mortuary.

 

=== 8. SERVICES REQUIRED ===

# Hygienic floor drains that are resistant to corrosion from blood and chlorine should be provided in all “wet areas” of the mortuary and should be directly connected to the sewer system. These areas include body preparation, autopsy space, etc. These areas require thorough cleaning after every procedure, using large quantities of water and decontaminating and disinfecting chemicals and soaps.<s>.</s>
# Sluicing facilities are to be provided in both the body- preparation and autopsy areas if they are not a common area.
# Open floor channels should be avoided. Where this is not possible, these should be covered by durable, flush- fitted stainless steel grids.
# No sewer connections external to the mortuary services should be made to the line between the wet area drains and the main sewer system in order to prevent backflow to other areas.
# The provision of hot and cold water in the facility is imperative, with all basins, sinks, ablution areas and autopsy tables being provided with both.
# Anti-backflow devices should be fitted to the water- supply lines serving mortuary table faucets to prevent backflow should supply water pressure fail.
# Electricity supply to the mortuary – particularly for refrigeration purposes – is to be provided from the essential supply system for the hospital. Alternatively, a back-up generator is to be supplied to allow for the maintenance of required temperatures in the cooling/freezing facilities in the mortuary.

 

=== 9. BIOLOGICAL SAFETY ===

# A Biosafety Laboratory Level 3 (BSL3) designation (R178-2012) is applicable for any decomposing bodies post-mortem area. This area is identified as a level-3 containment facility.
# BSL3 areas shall have restricted access and shall be separated from regular traffic flow routes.
# All doors opening into the BSL3 areas shall be appropriately labelled with biological safety hazard signage.
# Access to the BSL3 areas shall be through dedicated ventilated airlocks. A pressure differential of minimum +15Pa shall be maintained for the airlock relative to the BSL3 area. This pressure differential is relevant for when the doors are closed only. Room pressure differential gauges are to be fitted at the entrance to the BSL3 area.
# Airlock doors shall be interlocked such that only one door can be opened at a time, thereby preventing direct passage between the corridor and the BSL3 area.
# It is recommended <s>to create</s>that a transfer hatch be created for the transfer of goods between areas with differing biosafety-level classifications. This device shall be designed to preserve the integrity of the containment system and the mechanical ventilation design.
# Air exhausted from biosafety areas should be safely discharged to the outside with no chance for re-entrainment or contamination of other indoor spaces. Exhausts from biosafety areas should be vented at 3m above the roof level. Where such measures are not possible, exhaust air shall be EN1822 H13 HEPA filtered. Exhausts from biosafety areas should include anti-backflow devices.

 

=== 10. FINISHES TO FLOORS AND WALLS ===

# Walls and floor coverings within a mortuary should be easily cleanable and impervious to liquids and staining.
# Floors are to be of such a nature that they are not easily damaged by wheeled items that are moved over them. Vinyl floor coverings are not considered to be resilient enough for this purpose.
# Epoxy floor coverings are preferable, as these are easily maintained and do not have joints in them where liquids can accumulate to become a health risk.
# Corners between walls and floors shall be coved to facilitate the cleaning of these areas. These coving details should be solid and continuous without hidden formwork and cavities.
# Walls are to be coated with hard- wearing and washable materials/paint with provision made for trolley “bumpers” along walls exposed to high traffic. Wall coatings shall be impervious to damage from trolleys and mobile equipment.
# Materials such as vinyl sheeting should not be used to cover walls in wet areas. The risk of growth between the sheeting and the wall presents a health hazard to personnel working in the mortuary wet areas.
# Due to the potential presence of water on flooring it is essential that flooring be non-slip.
# Refer to the room requirement sheets herein and the '''''IUSS Materials and Finishes''''' guidance documents for further information.
# Surface- mounted services should be avoided to ensure smooth and washable surfaces. Where surface mounting of piping is unavoidable, this piping should be mounted on batons, such that the space behind the piping is readily accessible for cleaning.

 

=== 11. AUTOPSY EQUIPMENT/FIXTURES ===

# Equipment for the storage and transportation of bodies should meet environmental hygiene standards.
# In the majority of instances a<s>n</s> downdraft autopsy table is required within a hospital mortuary facility. This table should be one that is designed in such a way that there is a hot and cold water supply that is integral to table installation, as well as a drainage system that can automatically drain water/waste from the table to the sewer system of the facility.
# The autopsy table should have an integrated ventilation extraction or “downdraft” system in order to entrain noxious odours and infectious material that may emanate from a body. This can function to minimise the spread of any airborne pathogens from the body.
# Adequate stainless steel washing basins (at least one per autopsy table) must be provided in close proximity to the autopsy table for the use of personnel working in the facility.
# Electrical power must be provided from a 5 amp IPX5 waterproof single-socket outlet near the autopsy table to allow for the safe use of any electrical equipment that may be required during an autopsy.
# Lighting quality over the autopsy table must be exceptionally good. Refer to the lighting requirements specified in the room- requirement sheets herein and the '''''IUSS Building Engineering Services''''' guidance document for specifications.
# Adequately sized worktops must be provided along the walls of the autopsy area for equipment and specimens prior to storage.
# It is recommended that working surfaces of at least 500x2500mm be provided per autopsy table.
# A balance table for a bench-top scale is required. The scale can be either permanently mounted on the work surface or stored in the autopsy equipment store.
# A platform scale for measuring the weight of an entire body prior to any possible dissection/autopsy work being conducted is to be accommodated.
# Lockable <s>C</s>cabinets are required for the storage of autopsy equipment, as well as for any personal protective equipment morticians or medical examiners may require.
# Trolleys for the conveyance of bodies must be provided in the mortuary and adequate provision for the storage of these units must be available.
# The use of wood, such as for wooden doorframes, is not allowed in wet areas.
# Stainless steel bump rails or plates should be fitted in areas prone to damage from trolleys. These devices shall be fitted such that that they do not affect the integrity and cleanability of the walls and floors. These devices shall not create crevices or gaps which could <s>would</s> harbour pathogens or create a hygiene problem. Welded stainless steel sections shall be stainless steel Grade 316L

 

=== 12. VENTILATION ===

# <s>Mortuaries</s> Mortuary areas require good ventilation. The exhaust air is to be discharged to atmosphere such that it cannot be drawn back into the mortuary, any other ventilation inlet, or any indoor portion of the hospital.
# All external ventilation openings should be fly- and vermin- proof.
# Exhausted air may not pose a hazard to any person who is outside the mortuary. (See room-requirement sheets) Air exhausted from clinical areas should be safely discharged to outside with no chance for re-entrainment or contamination of other indoor spaces. Where these precautions are by no means possible, exhaust air shall be EN1822 H13 HEPA filtered.
# Sufficient ventilation is required for controlling noxious odours present in mortuaries and should also provide a means of protection to personnel working in the facility from possible airborne infections originating from corpses.
# Airborne- infection control is of particular concern and must be designed for in terms of the ventilation system. Tuberculosis, Hepatitis and HIV are <s>of</s> among the most regularly encountered diseases in mortuaries in South Africa and, as such, the spread of these pathogens beyond the mortuary, via a ventilation system, must be avoided by implementing the airborne- contamination control principles for high- risk areas in the ventilation system design. Refer to the '''''IUSS Building Engineering Services''''' guidance document for further guidance on airborne- contamination control principles.
# The ventilation system must be designed such that airborne pathogens that may be present in the body- holding area and autopsy room do not contaminate the remainder of the mortuary facility.
# No recirculation of air extracted from the clinical areas is permitted.
# Air from public areas, with the exception of viewing rooms, may be recirculated where this is in accordance with the National Building Regulations.
# Exhaust ventilation is to be designed in such a manner that this extracts from the areas with the highest risk of infection, while “clean” air is to be supplied into the lower- risk areas. This is to create a pressure cascade with cleaner areas being at a relatively higher air pressure than dirty areas.
# Air- supply registers should be at a high level and the extraction registers should be at a low level. The low- level extraction grilles shall not be more than 500mm above the finished floor level of the room <s>where</s> from which the extraction is taken <s>from</s>. Low- level air- register positions shall consider locations of water points and potential splashing during washing.

 

=== 13. AIR CONDITIONING ===

# The mortuary and autopsy area must have a temperature maintained <s>at</s> between 20˚C <s>to</s> and 21˚C.
# Public areas must be kept at a constant temperature between 23˚C and 25˚C.
# Air extracted from the mortuary may not be used for energy recovery or recirculation.

 

=== 14. REFRIGERATION EQUIPMENT DESIGN AND INSTALLATION ===

# All heat- rejection equipment associated with refrigeration in the body- storage facilities must be located on the outside of the mortuary, in a well-ventilated space at the rear of the fridge(s). Compressors installed on top of body cabinets on the inside of the mortuary are not acceptable. Heat build-up within the mortuary, as a result of this type of arrangement, potentially leads to equipment failure.
# Regularly serviced refrigeration equipment components should not be situated within the confines of the mortuary. Refrigeration technicians should not be required to climb onto or over a body cabinet to carry out any maintenance work. It is preferable to have refrigeration equipment situated in a separate ventilated area to the rear of the body cabinets. The designer is to refer to the selected heat- rejection equipment’s installation manual to determine free space and ventilation openings required around this equipment, since these details can vary between system types.
# Gauges indicating the temperature within the body cabinet must be clearly visible above the door of the unit in order that this can be readily monitored.
# The acceptable average temperature within a normal body cabinet or refrigerated room is between 2.0˚C and 6˚C. In instances where a body has to be kept for an extended period of time a cabinet temperature of at least -20˚C is required.
# In facilities where large quantities of bodies are kept, cold rooms for the storage of multiple bodies on trays are recommended.
# The materials used for the construction of the units are to be of stainless steel to facilitate cleaning and long-term maintenance of the equipment. Grade 316 stainless steel (18/10) is preferable over Grade 304 (18/8), as it offers better corrosion resistance'''.'''
# For welded stainless steel construction, Grade 316L or similar is required.
# If a facility is required to collect and retain forensic samples, refrigeration equipment should be provided for the preservation of these samples. Preferably this equipment should be placed in an area where <s>they</s> it can readily be secured from unauthorised access and tampering.

 

=== 15. SECURITY ARRANGEMENTS ===

# Due to the medical and legal nature of the contents of a mortuary, it is essential that a mortuary has good access control and security systems.
# Theft from mortuaries should be forestalled by, inter alia, constantly monitoring all entrances and preventing free access to mortuary areas. This is especially important for the body- storage areas. Access card or tag systems are open to misuse and are not an appropriate access- control measure. Combinations of tag and biometric access- control systems are recommended.
# Door closers with a “hold-open” mechanism should be installed on the mortuary room doors. This enables doors to close automatically with normal traffic, but can also be held open when moving equipment or trolleys through. “Crash”- type doors should be avoided as these are not easily cleanable and are subject to damage and abuse.
# It is recommended that a timed alarm be fitted to doors to ensure that they are closed shortly after any entrance or exit. This is to <s>mitigate</s> militate against the tendency of keeping doors open with some form of door stopper.
# Body cabinets are to be fitted with locks to prevent the unauthorised opening of these units to forestall the theft of any personal items of the deceased.
# In instances where historical problems relating to unauthorized entry into mortuaries is evident, it is recommended that closed-circuit TV systems be installed to help in monitoring and securing the facility.

= PART C – Operation =

=== 1. OBJECTIVES ===
The project planning, design, construction and commissioning should aim to provide:

# a safe, secure and functional environment for visitors and staff;
# low capital and ongoing operating costs (service, staffing and maintenance);
# an environmentally appropriate design solution; and
# a fully accessible, inclusive environment. 

=== 2. HEALTH AND SAFETY ===
In light of the above it is essential that every effort be made to ensure that personnel working in the mortuary are provided with all required personal protective equipment (PPE), as this is essentially an area where pathogens could be present and present a health risk to staff. The following items should be available to staff as a minimum:

# Rubber aprons (or similar impervious material)
# Latex gloves (or similar impervious material)
# Mesh gloves in facilities where post mortems are performed
# Disposable gowns
# Safety glasses or full-face visors.
# Waterproof footwear
# Face masks
# Respirators with the appropriate filters must be available for use in high-risk situations.
# Storage space for PPE

No one should be permitted to enter the body storage and preparation areas without donning appropriate gowns and footwear.

=== 3. MAINTENANCE ===
When designing the facility, every effort must be made to limit the amount of maintenance that would be necessary to keep it in good condition. Seamless surfaces for walls and floors are critical, as this will reduce ongoing maintenance costs. The following minimum requirements should be complied with:

# Seamless floor coverings required
# Radiuses corners ??? required between floors and walls.
# No sharp corners on any work surfaces that could injure people working in the area.
# Ceilings to be readily cleanable.
# Work surfaces are to be impervious to liquids and resistant to staining and corrosion.
# Refer to the room- requirement sheets herein and the IUSS Materials and Finishes guidance documents for further information on the general requirements for materials and finishes.
# All equipment requiring calibration, such as fridges and scales, are to be attended to on an annual basis or when it is suspected that they are defective in respect of their expected/intended performance

= PART D – User Room Requirements =

===== Room-requirement sheets =====

====== Table 3: Accommodation schedule ======
{| class="wikitable"
|'''Room Name'''
|'''Service Description'''
 
|'''Area'''

'''(m²)'''
|'''Min. Ceiling Height'''

'''(m)'''
|'''Occupancy'''

'''(Persons)'''
|'''Nominal Utilisation per day'''

'''(hours)'''
|-
|Ablution areas
|Ablution areas – male and female

One WHB per WC or urinal
|3 (per cubicle)
|2.8
|1
|4
|-
|Shower facilities
|Shower facilities – male and female
|3 (per cubicle)
|2.8
|1
|2
|-
|Changing room
|Staff changing room - lockers to be provided
|8
|2.8
|2
|2
|-
|Storage space
|Equipment and PPE storage space
 
|8
|2.8
|1
|1
|-
|Offices
|Office space – interview, body receiving, pathologist
|9
|2.8
|2
|8
|-
|Body/bier room
|Area where a body can be laid out for viewing and identification
|9
|2.8
|1
|8
|-
|Viewing room
|Viewing room – external to body- layout area
|9
|2.8
|4
|1
|-
|Autopsy room
|Autopsy facility – Autopsy table with water supply and discharge and extraction ventilation. WHBs and stainless steel working surfaces
|27
|2.8
|3
|3
|}

====== '''Table 4: Room services sheet''' ======
{| class="wikitable"
|'''Room Name'''
|'''Temp'''

'''(°C)'''
|'''Ventilation'''

'''(AC/h)'''
|'''Ventilation'''

'''Type'''
|'''Pressure Relative to'''

'''Ambient'''
|'''Wet Services'''
|'''SSO'''

'''400V'''
|'''SSO'''

'''230V'''
|'''Task Illuminance'''

'''(lux)'''
|'''Data Points'''
|'''Colour Rendering'''

'''(Ra)'''
|-
|Reception area
|22-25°C
|2
|Forced supply
|=
|
|0
|0
|100 at floor level
|0
|80
|-
|Visitors ablution areas
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|WC,

WHB
|0
|0
|150 at floor level
|0
|80
|-
|Public waiting area
|22-25°C
|2
|Forced supply
|<nowiki>+ </nowiki>
|
|0
|0
|100 at floor level
|0
|80
|-
|Offices
|22-25°C
|2
|Forced supply/ recirc.
|=
|
|0
|2
|300 at desk level
|1
|80
|-
|Circulation Spaces
|22-25°C
|10
|Forced supply/ recirc.
|=
|
|0
|0
|200 at floor level
|0
|80
|-
|Viewing room
|22-25°C
|2
|Forced supply
|<nowiki>+ </nowiki>
|
|0
|0
|100 at floor level
|0
|80
|-
|Layout room
|20-21°C
|2
|Forced extraction
|<nowiki>- </nowiki>
|WHB
|0
|0
|300 at table level
|1
|80
|-
|Storage space
|22-25°C
|4
|Forced supply
|=
|
|0
|1
|200 at floor level
|0
|80
|-
|Mortuary
|20-21°C
|12
|Forced extraction
|<nowiki>- </nowiki>
|WHB,

FD
|0
|1
|200 at floor level
|0
|80
|-
|Mortuary plant area
|n/a
|n/a
|Natural ventilation
|=
|
|1
|1
|150 at floor level
|0
|80
|-
|Autopsy table
|20-21°C
|20
|Forced extraction
|<nowiki>- </nowiki>
|CW Faucet
|0
|1
|5200 at table level
|0
|90
|-
|Autopsy room
|20-21°C
|20
|Forced extraction
|<nowiki>- </nowiki>
|WHBs,

FD
|0
|2
|500 at floor level
|1
|90
|-
|Changing room
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|WHB
|0
|1
|150 at floor level
|0
|80
|-
|Staff ablution areas
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|WHB,

WC
|0
|0
|150 at floor level
|0
|80
|-
|Shower facilities
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|CW + HW

Faucet
|0
|0
|150 at floor level
|0
|80
|}

====== '''Table 5: Room finishes''' ======
{| class="wikitable"
|'''Room Name'''
|'''Floor'''

'''Material'''
|'''Wall / Floor Interface'''
|'''Walls'''

'''Finish'''
|'''Ceiling'''

'''Finish'''
|'''Glazing'''

'''Type'''
|'''WHB'''
|'''Doors'''

'''Type'''
|-
|Ablution areas (all)
|Jointless vinyl sheet
|Skirting coved and finished as per floor
|Ceramic wall tiles with epoxy grout
|Washable acrylic paint
|Obscure laminate safety glass
|1 per WC or urinal
|Solid wood with galvanised steel or stainless steel sheet trolley plates
|-
|Public waiting area
|Jointless vinyl sheet
|Coved vinyl skirting
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Lockable glazed entrance door
|-
|Changing room
|Jointless vinyl sheet
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Obscure laminate safety glass
|0
|Solid wood with galvanised steel or stainless steel sheet trolley plates
|-
|Storage space
|Jointless vinyl sheet
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood with galvanised steel or stainless steel sheet cladding
|-
|Offices
|Jointless vinyl sheet
|Coved vinyl skirting
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood
|-
|Body Room
|Self- levelling epoxy
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood
|-
|Viewing Room
|Self- levelling epoxy
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood
|-
|Autopsy Room
|Self- levelling epoxy
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Obscure laminate safety glass
|Min 1 per autopsy table
|Solid wood with galvanised steel or stainless steel sheet cladding
|-
|Circulation Spaces
|Jointless vinyl sheet
|Coved vinyl skirting
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|
|}

= '''PART E – Examples and case studies''' =
Figure 4 demonstrates the relationships between the zones within the mortuary. In this example it is evident how visitors are managed and kept out of the working portions of the mortuary through segregation in the internal layout. The process flow of the bodies into, through and out of the mortuary has been well considered in that the flow is linear with bodies entering the mortuary <s>on</s>at one end of the facility and exiting at the other. Unfortunately, the restrictions presented by the location of the mortuary, as can be studied in Figure 3, has forced the design into a number of compromises relating to the external flow and access to the mortuary. Staff access is quite severely compromised in being through the mortuary lobby. This mortuary lobby, in the absence of a dedicated preparation room, has the potential of being used as one. This arrangement may impact negatively on the dignity of some staff, the dignity of the deceased, and mortuary security.

Visitors’ access to the mortuary and their adjacent toilets is near the hearse bay and turning areas. There is no natural screening of this entrance from the activities in the hearse bay and it is not inconceivable that visitors may inadvertently wander into the wrong area and be exposed to operational activities not appropriate for the bereaved.

The door sizes of the body storage rooms seem too small for the easy passage of a body trolley when compared to the double doors made available for the passage of the body from there through the remainder of the facility. Door size selection should not be limited by the fact that these are cold room doors. Where doors are too small for free passage of trolleys and porters, <s>their</s> the doors’ service life would be severely shortened and any savings made on the door selection would be lost to maintenance or retrofitting an improved solution.

The access to the technical area for maintenance of the refrigeration equipment in this example meets the recommendations. Here technicians do not need to enter the mortuary to perform the majority of their work and these areas are quite well separated from the admin and visitors’ areas.

 

=== 2. EXAMPLE 2: LARGE MORTUARY WITH AUTOPSY FACILITIES ===
Figure 5 shows the layout of a standardised mortuary design. This is a large facility with autopsy capacity. Figure 6 has been presented in order to promote an understanding of the interrelationship between the various functional parts of the mortuary.

Considering the entrances shown in Figure 5, it is clear that the designer has <s>taken some</s>made an effort to screen the <s>visitor’s</s> visitors’ entrance from the hearses’ entrance. The staff entrance is also well positioned. The staff ablution<s>s</s> facilities and showers are located between the clinical areas and the admin areas. This arrangement encourages good segregation and gowning practice when moving between the mortuary activities and external movement.

The staff and visitors’ access positions are located well away from the working clinical areas of the mortuary and are also relatively remote from each other. This aids in improving security as it discourages the staff and visitors from using the wrong entrances and thereby assists in identifying persons who are present in areas where they do not belong.

This design doesn’t have a dedicated body prep area and it is assumed that the weighing and measuring area is therefore used for this purpose.

The large sliding doors of the cold room in this example can be compared to the cold-room doors in Figure 3 as an indication of what the door size should be like to enable easy passage.

The layout in this example does not provide for a dedicated exit yard and bodies and hearses entering and leaving the facility do so through the same entrance. This arrangement increases the potential for mistakes in body handling.

The common use of the bier room as access to the ID room seems to be a compromise resulting from the limited space provided for these rooms.

====== '''3. EXAMPLE 3: LARGE MORTUARY WITH AUTOPSY FACILITIES''' ======
The example shown in Figure 7<s>Figure 7</s> is a standard facility layout, very similar to that of Figure 5<s>Figure 5</s>, with the most notable changes being the inclusion of a dedicated vehicle- exit yard and the omission of the technical service area. The addition of the exit detail resolves the criticism of the arrangement in Example 2, while the omission of the technical service area for the refrigeration equipment could present an access problem for maintenance technicians, as discussed earlier in this document.

The example in Figure 7<s>Figure 7</s> has also resolved the compromises <s>to</s> in the arrangement of the bier rooms and ID/viewing rooms’ available space, discussed in the previous example.

= '''DEFINITIONS''' =
In the context of this document the following definitions pertain:
{| class="wikitable"
|'''Autopsy room:''' Synonymous with post–mortem examination area or suite.
|-
|'''Containment facility:''' The part within the demarcated zone in which the most malodorous activities occur. This facility includes the decomposing bodies’ post-mortem examination room, airlock ante room, and a decontamination unit each for men and women. The containment facility is sealed off from the rest of the demarcated area.
|-
|'''Demarcated area:''' The demarcated area, including the post-mortem examination rooms and all supporting functional spaces is the area where most sensitive, costly and specialised processes occur.
|-
|'''Dignity of deceased:''' The principle that bodies are treated with the respect and dignity befitting any person prior to death.
|-
|'''Dissection room or suite:''' Synonymous with post-mortem examination area or suite.
|-
|'''Mortuary:''' A mortuary is a facility for temporary storage of the deceased pending identification, medico-legal investigation and despatch.
|-
|'''Natural death:''' A death <s>by</s>from natural causes which <s>is</s> are determined to have been the cause of illness <s>of</s>or an internal malfunction of the body <s>which was</s> not caused by external forces.
|-
|'''Post-mortem examination area or suite''': A room and its attached service rooms designed for the performing of post-mortem examinations.
|-
|'''Post-mortem examination:''' Examination after death, which may include performance of an autopsy.
|-
|'''Unnatural death:''' A death which is not classified as being a '''''Natural Death'''''
|-
|'''Work bench (or bench):''' Unless otherwise specified, this is a surface ergonomically dimensioned for use from the standing position. This is normally 900mm.
|-
|'''Work-station:''' Unless otherwise specified, this is a surface ergonomically dimensioned for use from the seated position. This is normally 750mm. ??
|}

Page Break

= '''BIBLIOGRAPHY''' =
To be sorted out and made consistent - as advised to Mr Van Reenen
{| class="wikitable"
|REQUIREMENTS FOR THE FACILITIES AND OPERATION OF MORTUARIES (Second Edition 2009), NPAAC Tier 4 Standard. Australian Government Department of Health and Ageing.
|-
|MANAGING HEALTH AND SAFETY RISKS IN NEW ZEALAND MORTUARIES.(November 2000) Dr Chris Wells and Dr Jeff Brownless
|-
|Mortuary design and hazards. J. clin. Path. (1961), 14, 103
|-
|Health Authority Abu Dhabi. Part B- Version 3.1, June 2011
|-
|Design and layout of Mortuary Complex for a Medical College and Peripheral Hospitals. (2011) BasantLalSirohiwal, Paliwal PK, Luv Sharma and Hitesh Charlwa
|-
|Planning and design of modern mortuary complex in tertiary care. IIJFMT 4(1) 2006. Dr Sanju Singh, Dr U.S. Sinha, Dr A.K. Kapoor, Dr S.K. Verma, Dr Dalbir Singh, Dr Susheel Sharma
|-
|Australian Health Facility guidelines. Revision v.4.0 16-Dec-10
|-
|Mortuary Facilities – Design and improvement guide. CSIR March 2002
|-
|Project development brief for the new academic M6 pathology forensic laboratory. Western Cape Department of Health, August 2009
|-
|National Code of Guidelines for Forensic Pathology Practice in South Africa. Edited by NFPSC Academic Sub-committee 20 August 2007
|-
|IUSS Building Engineering Services guidance document
|}
{{Expand}}
[[Category:Procurement and Operation]]

Maintenance

2022-07-27T09:48:49Z

Tmojanaga: /* Table 1 : IUSS Reference documents */ text fixing

Contents

OVERVIEW 5<s>6</s>

'''''Abbreviations''''' 9<s>8</s>

PART A – POLICY AND SERVICE CONTEXT 11<s>9</s>

Legislation, policies and international guidance 11<s>9</s>

1. LEGISLATIVE CONTEXT 11<s>9</s>

2. Further reference material and precedent<s>:</s> 11<s>9</s>

3. INFECTION PREVENTION AND CONTROL LEGISLATION 12<s>10</s>

4. BUILDING LEGISLATION 12<s>10</s>

5. SOUTH AFRICAN BUILDING PRACTICE POLICY AND GUIDELINES 12<s>10</s>

6. INTERNATIONAL DESIGN GUIDANCE 12<s>10</s>

Service Context 13<s>11</s>

PART B – PLANNING AND DESIGN 15<s>12</s>

1. INTRODUCTION 15<s>12</s>

2. LOCATION OF THE MORTUARY AND ACCESS ROUTES 16<s>13</s>

3. FACILITY CAPACITY 16<s>13</s>

4. SELECTING BODY STORAGE SYSTEMS 18<s>14</s>

5. FACILITY LAYOUT 18<s>15</s>

6. MORTUARY EQUIPMENT REQUIREMENTS 21<s>17</s>

7. MOVEMENT WITHIN A MORTUARY 22<s>18</s>

8. SERVICES REQUIRED 24<s>19</s>

9. BIOLOGICAL SAFETY 24<s>19</s>

10. FINISHES TO FLOORS AND WALLS 25<s>20</s>

11. AUTOPSY EQUIPMENT/FIXTURES 26<s>20</s>

12. VENTILATION 27<s>21</s>

13. AIR CONDITIONING 27<s>22</s>

14. REFRIGERATION EQUIPMENT DESIGN AND INSTALLATION 28<s>22</s>

15. SECURITY ARRANGEMENTS 28<s>22</s>

PART C – OPERATION 30<s>24</s>

1. OBJECTIVES 30<s>24</s>

2. HEALTH AND SAFETY 30<s>24</s>

3. MAINTENANCE 30<s>24</s>

PART D –USER ROOM REQUIREMENTS 32<s>32</s>

Room Requirement Sheets 32<s>32</s>

PART E – EXAMPLES AND CASE STUDIES 36<s>35</s>

Layout Examples 36<s>35</s>

1. EXAMPLE 1: SMALL MORTUARY ATTACHED TO HOSPITAL 38<s>36</s>

2. EXAMPLE 2: LARGE MORTUARY WITH AUTOPSY FACILITIES 39<s>37</s>

3. EXAMPLE 3: LARGE MORTUARY WITH AUTOPSY FACILITIES 43<s>40</s>

BIBLIOGRAPHY 46<s>42</s>

'''Table of Figures'''

Figure 1 Adjacency Diagram 1<s>16</s>

Figure 2: Access and Movement in a mortuary 1<s>18</s>

Figure 3 Example 1: Layout 1<s>35</s>

Figure 4 Example 1: Zoning & Access 1<s>36</s>

Figure 5 Example 2: Layout 1<s>38</s>

Figure 6 Example 2: Zoning and Access 1<s>39</s>

Figure 7 Example 3: Layout 1<s>40</s>

'''Table of Tables'''

Table 1 : IUSS Reference documents 8<s>7</s>

Table 2 Service Requirements 13<s>11</s>

Table 3 Accommodation Schedule 32<s>25</s>

TABLE 4 ROOM SERVICES SHEET 33<s>26</s>

TABLE 5 ROOM FINISHES 34<s>27</s>

''Version Control''
{| class="wikitable"
|''Template''
|''January 2013''
|''Tobias van Reenen''
|-
|''Discussion Draft 1''
|''February 2013''
|''Steve Fourie''
|-
|''Discussion Draft 5''
|''March 2013''
|''Steve Fourie''
|-
|''Discussion Draft 6''
|''May 2013''
|''Steve Fourie''
|-
|''Development Draft 1''
|''August 2013''
|''Tobias van Reenen''
|-
|''Development Draft 3.1''
|''February 2014''
|''Tobias van Reenen''
|-
|''Development Draft 3.1''
|''February 2014''
|''Prof J Vellema''
|}

Page Break

=='''OVERVIEW'''==

This document outlines the policy and service context and attempts to illustrate the desired planning principles and design considerations for mortuary services.

*''Part A'' outlines the South African legislation, policies and international guidance reference documents and the service context with respect to mortuary services;
*''Part B'' Planning and design;
*''Part C'' operation;
*''Part D'' user room requirements; and
*''Part E'' provides case studies.

Parts D and E are intended to demonstrate how the principles prescribed in Part A, B, and C can be applied in worked examples. Part D, if used directly, are deemed<s>-</s> to<s>-</s> satisfy the principles developed in Part B, but are not the only acceptable solutions.

Case studies (Part E) provide illustrative worked solutions and should not be adopted without appropriate contextual adaptation.

While this document outlines design requirements and acceptance criteria which have an impact on clinical services, these requirements are prescribed within the framework of the entire IUSS set of guidance documents and cannot be viewed in isolation. The following documents should be complied with, together with this document:

*IUSS: Regulations
*IUSS: Project Planning and Briefing
*IUSS: Environment and Sustainability
*IUSS: Hospital Design Principles
*IUSS: Infection Prevention and Control

Page Break

The following table identifies additional IUSS guideline documents which are recommended for reading in conjunction with this guideline.

==='''Table 1 : IUSS Reference documents'''===
{| class="wikitable"
|

'''CLINICAL'''

'''SERVICES'''
 
|Essential
|Recommended
|'''SUPPORT'''

'''SERVICES'''
|Essential
|Recommended
|'''HEALTHCARE ENVIRONMENT/ CROSSCUTTING ISSUES'''
|Essential
|Recommended
|'''PROCUREMENT'''

'''& OPERATION'''
|Essential
|Recommended
|-
|Adult Inpatient Services
|
|X
 
|Administration and Related Services
|
|
|Generic Room Requirements
|
|
|Integrated Infrastructure Planning
|
|
|-
|Clinical and Specialised Diagnostic Laboratory Guidelines
|
|X
|General Hospital Support Services
|
|X
|Hospital Design Principles
|
|
|Briefing Manual
|
|X
|-
|Mental Health
|
|
|Catering Services for Hospitals
|
|
|Building Engineering Services
|X
|
|Space Guidelines
|
|
|-
|Adult Critical Care
|
|
|Laundry and Linen Department
|
|X
|Environment and Sustainability
|
|
|Cost Guidelines
|
|
|-
|Emergency Centres
|
|
|Hospital Mortuary Services
|
|
|Materials and Finishes
|X
|
|Procurement
|
|
|-
|Maternity Care Facilities
|
|
|Nursing Education Institutions
|
|
|Future Healthcare Environments
|
|X
|Commissioning Health Facilities
|X
|
|-
|Adult Oncology Facilities
|
|
|Health Facility Residential
|
|
|Healthcare Technology
|
|
|Maintenance
|X
|
|-
|Outpatient Facilities
|
|X
|Central Sterile Service Department
|
|
|Inclusive Environments
|
|
|Decommissioning
|X
|
|-
|Paediatrics and Neonatal Facilities
|
|
|Training and Resource Centre
|
|X
|Infection Preventive Control
|X
|
|Capacity Development
|
|
|-
|Pharmacy
|
|
|Waste Disposal
|
|X
|Health Informatics
|
|
|
|
|
|-
|Primary Health Care Clinics and CHCs
|
|
|
|
|
|Regulations
|
|
|
|
|
|-
|Diagnostic Radiology
|
|
|
|
|
|
|
|
|
|
|
|-
|Adult Physical Rehabilitation
|
|
|
|
|
|
|
|
|
|
|
|-
|Sub-acute services
|
|
|
|
|
|
|
|
|
|
|
|-
|Facilities for Surgical Procedures
|
|
|
|
|
|
|
|
|
|
|
|-
|TB Services
|
|
|
|
|
|
|
|
|
|
|
|}

===== '''''Abbreviations''''' =====
{| class="wikitable"
|ACH
|Air changes per hour
|-
|ASHRAE
|American Society of Heating, Refrigerating, and Air-Conditioning Engineers
|-
|BMS
|Building Management System
|-
|BSL
|Biological safety level
|-
|CDC
|Centers for Disease Control (USA)
|-
|CSIR
|Council for Scientific and Industrial Research
|-
|FD
|Floor drain
|-
|FPS
|Forensic Pathology Service
|-
|HVAC
|Heating Ventilation Air Conditioning
|-
|HBA
|Hazardous biological agents
|-
|HCS
|Hazardous chemical substances
|-
|HEPA
|High efficiency particulate air filters
|-
|IPC
|Infection prevention and control
|-
|ISO
|International Standards Organisation
|-
|MDR TB
|Multi-drug resistant TB
|-
|NDoH
|National Department of Health
|-
|NBR
|National Building Regulations
|-
|<s>NDoH</s>
|<s>National Department of Health</s>
|-
|NHS
|National Health Service (UK health service)
|-
|NIOSH
|National Institute of Occupational Safety and Health (US agency)
|-
|O&M
|Operating and Maintenance (manual)
|-
|OHS
|Occupational health and safety
|-
|OQ
|Operational qualification
|-
|PGWCDoH
|Provincial Government Western Cape Department of Health
|-
|PPE
|Personal protective equipment
|-
|PQ
|Performance qualification
|-
|RDS
|Room data sheets
|-
|RH
|Relative humidity
|-
|SABS
|South African Bureau of Standards
|-
|SAO
|Senior Administrative Officer
|-
|SAPS
|South African Police Service
|-
|SI
|<s>Le Systeme International d' Unites</s> Le Système International d’Unités
|-
|SOP
|Standard Operating Procedures
|-
|SS
|Stainless steel
|-
|TB
|Tuberculosis
|-
|WC
|Toilet
|-
|WHB
|Wash-hand basin
|-
|WHO
|World Health Organisation
|-
|XDR TB
|Extreme (or extensively) <s>-</s>drug- resistant TB
|-
|
|
|-
|
|
|-
|
|
|}

= PART A – Policy and service context =

===== Legislation, policies and international guidance =====

=== 1. LEGISLATIVE CONTEXT ===
The following documents, as amended (though not an exhaustive list) pertain and contain an additional resource of information which would supplement and provide the basis of a design brief. A finer sense of standard operating procedures and legislative context is likely to inform and enhance the design process, so the professional teams are encouraged to use these as an additional resource:
 

*Inquest Act<s>,</s> 58, 1959
*National Health Act<s>,</s> 61, 2003
*Government Notice R363, 2013 [Regulations relating to the management of human remains]
*Government Notice R178, 2012 [Regulations relating to the registration of microbiological laboratories and the acquisition, importation, handling, maintenance and supply of human pathogens]

*Health Professions Amendment Act, 29, 2007
*Criminal Procedures Act<s>,</s> 51, 1977
*Births and Deaths Registration Act<s>,</s> 51, 1992
*National Environmental Management: Waste Act<s>,</s> 59, 2008
*National Archives of South Africa Act<s>,</s> 42, 1996

*Regulations regarding the Rendering of Forensic Pathology Service, ''Government Gazette'' No 30075. No R636, 20 July 2007
*Space Planning Norms and Standards for Office Accommodation used by Organs of State, ''Government Gazette'' No 27985. No 1665, 2 Sept 2005
*Western Cape Health Care Waste Management Draft Bill
*Municipal by<s>-</s>laws, as applicable
*National Code of Guidelines for Forensic Pathology Practice in South Africa, 20 Aug 2007

*Standard Operating Procedures, Forensic Pathology Service, PGWCDoH, 2006
*Biosafety in Microbiological and Biomedical Laboratories, U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention and National Institutes of Health, Fifth Edition, <s>2007</s> US Government Printing Office, Washington: 2007

 

==== 2. Further reference material and precedent<s>:</s> ====

*Standard specification for air-conditioning and ventilation systems, Western Cape Department of Public Works, 1998
*Fire security: a guide for architects, Western Cape Department of Public Works, 1998
*Standard electrical specification, South African Department of Public Works, 2005
*Facilities for mortuary and post-mortem room services, NHS Estates, 2001, ISBN 0-11-322000-00
*Part B – Health facility briefing and planning, Australasian Health Facilities Guidelines, 2007

*CKS 336: 2013 Mortuary Trolleys - SABS

==== 3. INFECTION PREVENTION AND CONTROL LEGISLATION ====
The National Infection Prevention and Control Policy and Strategy document makes specific reference to certain Acts and their relevant regulations, which bear relevance to the development and implementation of these health facility guidelines. These are:

*The South African Constitution, 1996 [Sections 2, 24, 27, 36 and 39], as amended
*The Occupational Health and Safety Act of 1993, Act No 85 of 1993 [Section 8(1)]

*Government notice R1390 of 27 December 2001 [Hazardous Biological Agents Regulation] as promulgated under Section 43 of the Occupational Health and Safety Act of 1993
*Government notice R908 of 27 June 2003 [Hazard Analysis Critical Control Point Regulation] as promulgated under Section 15(1) of the Foodstuffs, Cosmetic and Disinfectants Act of 1972
*The Environmental Conservation Act of 1989, Act No 73 of 1989
*The Foodstuffs, Cosmetic and Disinfectants Act of 1972, Act No 45 of 1972 

==== 4. BUILDING LEGISLATION ====
The following legislation and regulations impact and provide guidance on the provision and design of health care facilities as above:

*The National Environmental Management Act 107 of 1998, as amended
*Building regulations and Building Standards Act 103 of 1977, as amended
*National Building Regulations; SANS 10400:2010, Code of Practice for the Application of the National Building Regulations

*Promotion of Equality and Prevention of Unfair Discrimination Act No 4 of 2000
*General Procedures and Loadings adopted in the Design of Buildings, SABS 0160, 1993
*Structural Use of Concrete Design, SABS 0100-1, 1992
*Structural Use of Concrete – Materials and Execution of Work, SABS 0100-2, 1992
*Specification for Civil Engineering Construction SABS 1200 

=== 5. SOUTH AFRICAN BUILDING PRACTICE POLICY AND GUIDELINES ===

*R158 of 1980 regulations pertaining to Private Hospitals and Unattached Operating Theatres – R198
*Good Pharmacy Practice, Board Notice 129 of 2004, as amended [see Chapter 1].

=== 6. INTERNATIONAL DESIGN GUIDANCE ===

*ASHRAE Standard 52.2, “Method of Testing General Ventilation Air-Cleaning Devices for Removal Efficiency by Particle Size”, 1992, 1999b
*ASHRAE Standard 62, “Ventilation for Acceptable Indoor Air Quality”, 1989
*ASHRAE. “HVAC Design Manual for Hospitals and Clinics, 2003”, 1989
*CIBSE Applications Manual AM10:1997 “Natural Ventilation in Non-Domestic Buildings”, 1998
*CIBSE Applications Manual AM13:2000 “Mixed Mode Ventilation,” 2000

*ASHRAE Standard 170, “Ventilation of Health Care Facilities”, 2008
*QASA. “Know Your Rights” [Accessibility & the Built Environment]
*Department of Health and Human Services. “Environmental Control for Tuberculosis: Basic Upper-Room Ultraviolet Germicidal Irradiation - Guidelines for Healthcare Settings”, 2009
*WHO. “WHO Policy on TB Infection Control in Health-Care Facilities, Congregate Settings and Households”, 2009

Guidance has also been provided by AIA (USA), NHS (UK), and Australian Health Facility Guidelines on Healthcare Building Design. Additional references can be sourced from www.tb-ipcp.co.za

===== Service Context =====

The following table gives an indication of the service requirements for mortuaries within different types of public hospitals.

====== Table 2: Service Requirements ======
{| class="wikitable"
|'''Service'''
|'''District'''
|'''Regional'''
|'''Tertiary'''
|'''Central'''
|'''Specialised'''
|-
|Small (beds)
|50-150
|Min 300
|Min 400
|
|
|-
|Medium (beds)
|150-300
|
|
|
|
|-
|Large (beds)
|300-600
|Max 800
|Max 800
|Max 1200
|Max 600
|-
|Training
|Where practical
|Where practical
|Optional
|Yes. Attached to medical school
|
|-
|Conduct research
|
|
|
|Yes
|
|-
|'''Mortuary'''
|
|
|
|
|
|-
|Short-term stay (2˚C)
|Yes
|Yes
|Yes
|Yes
|
|-
|Long-term stay (-15˚C)
|Yes
|Yes
|Yes
|Yes
|
|-
|Autopsies (20°C -21°C)
|Yes
|Yes
|Yes
|Yes
|Yes
|}

For the determination of capacity requirements of mortuaries refer to the recommendations further on in this document.

This guidance document relates to mortuaries located within and serving hospitals, with respect to persons that die due to natural causes in that hospital. This document excludes mortuaries <s>exclusively</s> dealing exclusively with cases that require medico-legal investigation of deaths from unnatural causes.

Post mortems conducted in hospital mortuaries should be limited to conducting investigations and procedures where no medico-legal investigation is required and death from natural causes is suspected.

Hospital deaths from natural causes and those suspected to be of unnatural cases should not be managed in the same facility unless the hospital mortuary is equipped to comply with the specific legal requirements as <s>it</s> they relate<s>s</s> to the chain of evidence, etc. The requirements for forensic- pathology service mortuaries are not exhaustively detailed in this document.

It is also noted that some hospitals may opt to contract out the removal and storage of decedents to private undertakers and these hospitals may <s>only</s> require only the minimum in terms of refrigerated body storage.

= PART B – Planning and Design =

=== 1. INTRODUCTION ===

# All state- run mortuary facilities fall within the domain of the Department of Health, both National and Provincial;<s>,</s> and in an effort to provide engineers and architects who are required to either design new facilities or upgrade existing facilities, this document provides the minimum standards necessary to comply with existing legislation.
# This document will provide designers of this type of facility with guidelines as to what is required in terms of the following:

*Type of service and package of care being provided
*Mortality rate
*Access and egress
*Discreet management of human remains

*Size and dimensions of the actual facility
*Positioning of mortuaries within hospitals
*Finishes of surfaces in these facilities
*Water- supply requirements
*Drainage requirements

*Electrical supply and lighting requirements
*Installation requirements for equipment and services
*Body-storage requirements
*Body-handling facilities
*Body-holding areas

*Body-viewing area
*Autopsy equipment (tables)
*Air conditioning and ventilation requirements (for infection and indoor air quality control)
*Security of the facility

# In addition to the items listed above, it is also necessary to consider the needs of visitors to these facilities, particularly those wishing to, or who are required to, identify bodies. In line with this it is also necessary to take the handling of bodies into consideration as it pertains to issues of patient dignity.
# Forensic pathology mortuaries are not <s>considered</s> exhaustively described in this document, although the majority of mortuaries do have basic facilities for general autopsies that are not necessarily medico-legal in nature. A forensic pathology mortuary has laboratory facilities attached that are outside the scope of regular mortuaries found in hospitals and at police stations. It should be noted that there are a number of principles that hold true for both hospital and forensic pathology mortuaries.
# Compliance with the requirements of the Occupational Health and Safety Act (Act 85 of 1993 as amended) are to be complied with at all times during the design of a mortuary.

 

=== 2. LOCATION OF THE MORTUARY AND ACCESS ROUTES ===

# The position of the mortuary in a hospital should be such that the mortuary is easily accessible to mortuary staff and related service providers without presenting either aesthetic, emotional or ethical problems for unrelated hospital staff, patients or visitors. Visitors to the mortuary, however, should be provided with clear and direct access to the mortuary upon arrival at the hospital, without having to travel unnecessarily through hospital departments.
# Where bodies are moved into or out of the mortuary, they should not be moved through general public-access areas. Appropriate routes would include technical service or goods corridors and through the hospital’s support services yard.
# Special considerations should be given to plans for contingency access to the mortuary in the event of case- load surges, which may <s>be</s> result from disasters.
# Bodies should not be held for any period in any locations between the body- holding rooms within clinical areas and the mortuary.
# Where a mortuary unit is used jointly between the hospital and the local authority it is beneficial for the mortuary to be in a building separate from the main hospital building.
# The delivery of bodies to the mortuary and their subsequent removal from the facility is to be such that it is carried out in a manner that is not visible to the general public, preferably in a covered and enclosed area.
# While siting and access are important aspects when locating a mortuary, it is also important to provide the mortuary with pleasant surroundings in order to promote the dignity of those working in or visiting the mortuary. 

=== 3. FACILITY CAPACITY ===

# The layout and size of a mortuary is largely determined by the number of bodies stored and whether body storage needs to be in cabinets or in refrigerated rooms.
# In order to determine the storage capacity of a hospital mortuary it is recommended that historical data, where available, should be used. In the South African context it is suggested that a storage capacity of between 5 and 10 bodies per 100 beds should be used. This varies with the rural or urban location of the facility. This capacity should not take into account the need to store bodies from deaths which are not hospital related, typically motor-vehicle accident deaths and deaths from criminal activity. Requirements for contingency storage capacity related to disaster management should be considered.
# The body storage capacity required can be estimated on the basis of the number of deaths per year in the hospital, the length of time of holding and the required body store occupancy rate. The number of body trays can be calculated from Equation 1<s>Equation 1</s> below.

-Equation 1

Where:

BT = Number of body trays

D = Number of deaths per year requiring body trays

S = Average length of stay (in days)

R = Required body tray occupancy rate

[Text Box]

#The estimated storage capacity for bodies in a mortuary could be confounded by a number of local factors, such as:

*Mortality rate from natural causes.
*Mortality rate from infectious disease. (Highly contagious disease deaths require special storage facilities.)

#Where the hospital is expected to place the body in cold storage until collection by forensic pathology services the following additional factors should be considered:

*Mortality rate from foul play.
*Mortality rate from traffic incidents.

 

=== 4. SELECTING BODY-STORAGE SYSTEMS ===

# Body-storage systems are principally divided into refrigerated rooms or body cabinets. Differences within these system types occur where specific temperatures or sizes are required based on risk, need and capacity requirements.
# Where a system of functionally separate body cabinets is selected, this system would have an inherent redundancy against failure, as the failure of a single unit would not necessarily imply a system failure. In contrast, a refrigerated room would require less maintenance and would have a lower frequency of failure; however a single component failure could be critical if standby condensing units are not installed. For this reason, multiple- cabinet systems are recommended for areas where expected maintenance response times would negatively affect the mortuary’s operations.
# It is possible to have a requirement for a mixture of refrigerated rooms and body cabinets. This could be affected by local cultural requirements such as for families <s>which</s> who object to bodies sharing storage space, the case load of the facility or the case profile.
# Where there is a requirement for the long-term storage of bodies, these are to be kept at a lower temperature than would be the case in a refrigerated room. In this instance separate body cabinets are required. Long- term storage of bodies is most often required when an indigent person dies and difficulty is experienced in locating the next of kin, as the person cannot legally be buried until this process has been completed.
# In general, smaller facilities rely on body cabinets for the storage as these facilities do not have the space or the need for the large-scale storage of bodies, <s>and they do not</s>they would not appreciate the functional flexibility offered by these systems. By rule of thumb, any facility that has the requirement to store <s>less</s> fewer than 12 bodies at any given time should use body cabinets. This <s>provides</s> gives the option of providing both short- and long-term storage with the smallest facility and equipment footprint.
# Bodies suspected of having succumbed to a highly contagious and dangerous disease require special treatment. These should be stored in such a manner that they do not present a hazard to personnel working in the mortuary. Typically these bodies should be stored at the same temperature<s>s</s> <s>the same</s> as <s>for</s> long- stay bodies, e.g. -15˚C, and should be placed in hermetically sealed plastic body-bags.
# Provision for the secure cold storage of body parts should <s>also</s> be provided. 

#FACILITY LAYOUT

#As mentioned, the layout and size of a mortuary is going to be largely determined by case load and whether storage is in cabinets or refrigerated rooms. It is acceptable to have a mixture of refrigerated rooms and body cabinets.

#In a mortuary facility there are a number of separate areas that need to be considered other than the body- storage areas. These include:

#'''Reception area''' for members of the public who are required to visit the mortuary on official business – typically to identify bodies or to pay their last respects to a deceased person.

#'''Ablution areas''' for staff. Where unisex ablutions are provided it is recommended that <s>the</s> no urinal is provided.

#<s>'''Visitor’s'''</s> '''Visitors’ admin space''' close to the reception area, where any admin or official business related to the identifying of a body can be completed.

#'''Staff admin space''' close to the point where a body is delivered to the mortuary, so that pertinent documentation can be completed – both with respect to the delivery of the body, as well as when the body is released from the mortuary again.

#'''Office space''' for pathologists to write up reports <s>for</s> in instances where this could be required. This is dependent on the size of the mortuary as small facilities would not require a separate room(s) for this function.

#'''Waiting''' and circulation areas for visitors to the mortuary.

#'''Viewing room,''' from where a body can be viewed through a curtained glass window between this space and the body- display room.

#'''Body- display''' room, where a body is placed for identification purposes. There is to be access to this area via a lockable door to the viewing room <s>for</s> in instances where it is necessary for non-mortuary personnel to have direct access to a body in the viewing room. There is to be access to this room from the body- storage area to allow bodies to be brought in for display purposes.

#'''Body preparation''' area, where a body that is delivered to the mortuary needs to be attended to prior to it being placed in the viewing room.

#'''Shower facilities''' (staff)

#'''Changing room''' (staff)

#'''Storage space''' for equipment and clothing that is worn in the body-preparation and autopsy spaces.

#'''Body-storage''' facility (cold room or refrigerated cabinets), depending on the length of time that bodies are expected to be kept in the facility.

#'''Autopsy facility,''' where the cause of death can be determined. This facility will differ from mortuary to mortuary, depending on whether forensic or standard medical autopsies to determine the cause of death are conducted.

[GroupDrawing]
 

#Figure 1<s>Figure 1</s> is an example of an adjacency diagram for a typical mortuary. In this instance the proximity also relates to visual and physical access. It is also understood that not all mortuaries would require all of the spaces indicated in this diagram, and that some of the spaces shown as being '''''immediately adjacent''''' could be included as a single area if functionality and privacy considerations permit it.

#There remains abundant scope for variations in the planning of the layouts making up the mortuary. and the hospital architect should consult with all stakeholders to arrive at an ideal solution.

#When developing the facility layout, careful consideration should be given to the routes through the facility of staff, bodies and visitors. These routes should overlap as little as possible and there should never be a common entrance for bodies and staff or visitors.

#The room requirement sheets are presented in ''PART D – User Room Requirements<s>PART D –User Room Requirements</s>''of this document.

#Storage space for body lifts must be provided.

#Suitable sluicing facilities are required to be able to clean equipment and fabrics after completion of any work in the mortuary facility.

 

#MORTUARY EQUIPMENT REQUIREMENTS

#Equipment for storage and transportation of bodies should meet environmental hygiene standards.

#For mortuary trolley design and supply, the SABS published standard '''''CKS336:2013 Mortuary Trolleys''''' is recommended. It should be noted that this is not a normative South African National Standard, and individual requirements may differ.

#'''Body-cabinet''' selection and installation requires the following considerations:

#Three-level body cabinets could be selected which have a single door to give access to all of the body trays, for instances where separation between bodies is required. Alternatively, cabinets that provide a single door for access to all the body trays are acceptable.

#It is critical that bariatric (obese) bodies are catered for in each cabinet. The lowest-level tray should be designed for this purpose.

#Special consideration is to be given to the provision of capacity for storage of juvenile and infant decedents. The handling of these bodies is an especially sensitive and emotive issue, and separate storage in dedicated cabinets is recommended.

#Body lifts must be supplied to facilitate the loading of bodies into and removal of bodies from the cabinets. Body lifts help to preserve dignity when handling bodies, while at the same time making it easier and safer for mortuary personnel to handle bodies.

#A clear space must be provided in front of the body cabinets to allow for the placing of a corpse into the cabinets. It is recommended that there be at least a 3m clearance between the front of the cabinet and any fixed structure. This is to accommodate whatever means of conveyance is used to transport a corpse to ?? and then load it into the cabinet.

#Due to the vast array of cabinets available on the market and the lack of an appropriate national standard, it is not yet possible to prescribe sizes for refrigerated cabinets in this guide.

#The required cabinet size is fundamental when designing a mortuary. Where space is not too limited and there are no indications that there may be cultural concerns relating to the storage of bodies together in a cold room, it is recommended that cold rooms be used. Cold rooms offer space savings when compared to cabinets.

#A temperature gauge must be installed close to the door of the facility to indicate the storage-space temperature. This gauge should have an alarm system connected to it to give a warning should there be an unacceptable rise in temperature in the storage space. Typically, if the temperature should rise more than 2˚C above the set temperature, an alarm should be activated at a point that is manned at all times.

#Body cabinets and refrigerated rooms must be supplied with electrical power from the hospital’s essential services electrical supply.

#A slop hopper is to be provided to allow for the cleaning of the body preparation and autopsy areas, in particular after the completion of any work carried out in these areas.

#To allow for the rinsing of body parts and organs, during an autopsy procedure it is important that suitable basins be provided in close proximity to <s>the</s>a downdraft autopsy table.

#Where there is transition between “clean” and “dirty” areas, provision is to be made to allow for the cleaning of footwear in a “transitional” area. This helps prevent the transport of contaminants from dirty areas.

 

#MOVEMENT WITHIN A MORTUARY

#Movement of members of the public visiting the mortuary is to be restricted such that they do not have access to the body- preparation or autopsy areas. (Figure 2<s>Figure 2</s>)

#The facility must be available within the mortuary where body identification can be conducted in a private and dignified manner. This viewing area should consist of a body- display or layout room with an adjacent viewing room, where the body can be viewed through a curtained shatter-proof glass window.

#The requirement for a viewing and identification area also pertains to hospitals which outsource their mortuary services.

#The viewing room and visitors’ admin rooms should be designed such that counselling can be conducted in a pleasant environment for bereaved persons.

#The design of the viewing facility should allow <s>for</s> adequate space for persons to view a body in a dignified manner.

#Direct access to the body- layout room from the viewing room is to be provided via a lockable door, to allow visitors access to the body.

#Ablution facilities are to be available to members of the public who are required to visit the mortuary complex.

#[GroupDrawing]Where a dedicated room, as described above, cannot be allocated for placing a body for viewing purposes, the persons who are viewing a body should be given a private space for viewing the body through a curtained shatter-proof glass window, as a minimum.

#Adequate facilities to accommodate at least 7 visitors are to be provided.

#Staff access to the mortuary facility is to be separate from the general public. (Figure 2)

#Mortuary staff change rooms should be provided with secure lockers for storage of street garments, lab coats, personal protective equipment and valuables. <s>Street garments and lab garments</s>

#Mortuary staff may have completely separate ablution facilities from those used by the general public requiring access to the mortuary facility.

#In a free- standing mortuary building the delivery to and removal of bodies from the facility may be via the same access point to the building.

#A mortuary that forms an integral part of a hospital will require separate routes for receiving bodies and the subsequent removal thereof.

#In the unusual event that a body arrives from outside <s>of</s> the hospital, the normal route of removal should be used for receipt of the body.

#A clear distinction is to be made between “clean”,” “dirty” / “wet” and “transitional” areas. This is best achieved by creating a physical “RED LINE” on the floor indicating the separation of these areas, with “yellow lines” used to demarcate “transitional” areas. Receptacles for the collections of dirty clothing, etc, must be made available at the transition area from <s>a</s> dirty to clean areas and in change rooms.

#A well-drained facility for washing <s>of</s> vehicles which have been contaminated with decomposed bodies or <s>bodily</s> body fluids should be provided in an enclosed area, near to the mortuary.

 

#SERVICES REQUIRED

#Hygienic floor drains that are resistant to corrosion from blood and chlorine should be provided in all “wet areas” of the mortuary and should be directly connected to the sewer system. These areas include body preparation, autopsy space, etc. These areas require thorough cleaning after every procedure, using large quantities of water and decontaminating and disinfecting chemicals and soaps.<s>.</s>

#Sluicing facilities are to be provided in both the body- preparation and autopsy areas if they are not a common area.

#Open floor channels should be avoided. Where this is not possible, these should be covered by durable, flush- fitted stainless steel grids.

#No sewer connections external to the mortuary services should be made to the line between the wet area drains and the main sewer system in order to prevent backflow to other areas.

#The provision of hot and cold water in the facility is imperative, with all basins, sinks, ablution areas and autopsy tables being provided with both.

#Anti-backflow devices should be fitted to the water- supply lines serving mortuary table faucets to prevent backflow should supply water pressure fail.

#Electricity supply to the mortuary – particularly for refrigeration purposes – is to be provided from the essential supply system for the hospital. Alternatively, a back-up generator is to be supplied to allow for the maintenance of required temperatures in the cooling/freezing facilities in the mortuary.

 

#BIOLOGICAL SAFETY

#A Biosafety Laboratory Level 3 (BSL3) designation (R178-2012) is applicable for any decomposing bodies post-mortem area. This area is identified as a level-3 containment facility.

#BSL3 areas shall have restricted access and shall be separated from regular traffic flow routes.

#All doors opening into the BSL3 areas shall be appropriately labelled with biological safety hazard signage.

#Access to the BSL3 areas shall be through dedicated ventilated airlocks. A pressure differential of minimum +15Pa shall be maintained for the airlock relative to the BSL3 area. This pressure differential is relevant for when the doors are closed only. Room pressure differential gauges are to be fitted at the entrance to the BSL3 area.

#Airlock doors shall be interlocked such that only one door can be opened at a time, thereby preventing direct passage between the corridor and the BSL3 area.

#It is recommended <s>to create</s>that a transfer hatch be created for the transfer of goods between areas with differing biosafety-level classifications. This device shall be designed to preserve the integrity of the containment system and the mechanical ventilation design.

#Air exhausted from biosafety areas should be safely discharged to the outside with no chance for re-entrainment or contamination of other indoor spaces. Exhausts from biosafety areas should be vented at 3m above the roof level. Where such measures are not possible, exhaust air shall be EN1822 H13 HEPA filtered. Exhausts from biosafety areas should include anti-backflow devices.

 

#FINISHES TO FLOORS AND WALLS

#Walls and floor coverings within a mortuary should be easily cleanable and impervious to liquids and staining.

#Floors are to be of such a nature that they are not easily damaged by wheeled items that are moved over them. Vinyl floor coverings are not considered to be resilient enough for this purpose.

#Epoxy floor coverings are preferable, as these are easily maintained and do not have joints in them where liquids can accumulate to become a health risk.

#Corners between walls and floors shall be coved to facilitate the cleaning of these areas. These coving details should be solid and continuous without hidden formwork and cavities.

#Walls are to be coated with hard- wearing and washable materials/paint with provision made for trolley “bumpers” along walls exposed to high traffic. Wall coatings shall be impervious to damage from trolleys and mobile equipment.

#Materials such as vinyl sheeting should not be used to cover walls in wet areas. The risk of growth between the sheeting and the wall presents a health hazard to personnel working in the mortuary wet areas.

#Due to the potential presence of water on flooring it is essential that flooring be non-slip.

#Refer to the room requirement sheets herein and the '''''IUSS Materials and Finishes''''' guidance documents for further information.

#Surface- mounted services should be avoided to ensure smooth and washable surfaces. Where surface mounting of piping is unavoidable, this piping should be mounted on batons, such that the space behind the piping is readily accessible for cleaning.

 

#AUTOPSY EQUIPMENT/FIXTURES

#Equipment for the storage and transportation of bodies should meet environmental hygiene standards.

#In the majority of instances a<s>n</s> downdraft autopsy table is required within a hospital mortuary facility. This table should be one that is designed in such a way that there is a hot and cold water supply that is integral to table installation, as well as a drainage system that can automatically drain water/waste from the table to the sewer system of the facility.

#The autopsy table should have an integrated ventilation extraction or “downdraft” system in order to entrain noxious odours and infectious material that may emanate from a body. This can function to minimise the spread of any airborne pathogens from the body.

#Adequate stainless steel washing basins (at least one per autopsy table) must be provided in close proximity to the autopsy table for the use of personnel working in the facility.

#Electrical power must be provided from a 5 amp IPX5 waterproof single-socket outlet near the autopsy table to allow for the safe use of any electrical equipment that may be required during an autopsy.

#Lighting quality over the autopsy table must be exceptionally good. Refer to the lighting requirements specified in the room- requirement sheets herein and the '''''IUSS Building Engineering Services''''' guidance document for specifications.

#Adequately sized worktops must be provided along the walls of the autopsy area for equipment and specimens prior to storage.

#It is recommended that working surfaces of at least 500x2500mm be provided per autopsy table.

#A balance table for a bench-top scale is required. The scale can be either permanently mounted on the work surface or stored in the autopsy equipment store.

#A platform scale for measuring the weight of an entire body prior to any possible dissection/autopsy work being conducted is to be accommodated.

#Lockable <s>C</s>cabinets are required for the storage of autopsy equipment, as well as for any personal protective equipment morticians or medical examiners may require.

#Trolleys for the conveyance of bodies must be provided in the mortuary and adequate provision for the storage of these units must be available.

#The use of wood, such as for wooden doorframes, is not allowed in wet areas.

#Stainless steel bump rails or plates should be fitted in areas prone to damage from trolleys. These devices shall be fitted such that that they do not affect the integrity and cleanability of the walls and floors. These devices shall not create crevices or gaps which could <s>would</s> harbour pathogens or create a hygiene problem. Welded stainless steel sections shall be stainless steel Grade 316L

 

#VENTILATION

#<s>Mortuaries</s> Mortuary areas require good ventilation. The exhaust air is to be discharged to atmosphere such that it cannot be drawn back into the mortuary, any other ventilation inlet, or any indoor portion of the hospital.

#All external ventilation openings should be fly- and vermin- proof.

#Exhausted air may not pose a hazard to any person who is outside the mortuary. (See room-requirement sheets) Air exhausted from clinical areas should be safely discharged to outside with no chance for re-entrainment or contamination of other indoor spaces. Where these precautions are by no means possible, exhaust air shall be EN1822 H13 HEPA filtered.

#Sufficient ventilation is required for controlling noxious odours present in mortuaries and should also provide a means of protection to personnel working in the facility from possible airborne infections originating from corpses.

#Airborne- infection control is of particular concern and must be designed for in terms of the ventilation system. Tuberculosis, Hepatitis and HIV are <s>of</s> among the most regularly encountered diseases in mortuaries in South Africa and, as such, the spread of these pathogens beyond the mortuary, via a ventilation system, must be avoided by implementing the airborne- contamination control principles for high- risk areas in the ventilation system design. Refer to the '''''IUSS Building Engineering Services''''' guidance document for further guidance on airborne- contamination control principles.

#The ventilation system must be designed such that airborne pathogens that may be present in the body- holding area and autopsy room do not contaminate the remainder of the mortuary facility.

#No recirculation of air extracted from the clinical areas is permitted.

#Air from public areas, with the exception of viewing rooms, may be recirculated where this is in accordance with the National Building Regulations.

#Exhaust ventilation is to be designed in such a manner that this extracts from the areas with the highest risk of infection, while “clean” air is to be supplied into the lower- risk areas. This is to create a pressure cascade with cleaner areas being at a relatively higher air pressure than dirty areas.

#Air- supply registers should be at a high level and the extraction registers should be at a low level. The low- level extraction grilles shall not be more than 500mm above the finished floor level of the room <s>where</s> from which the extraction is taken <s>from</s>. Low- level air- register positions shall consider locations of water points and potential splashing during washing.

 

#AIR CONDITIONING

#The mortuary and autopsy area must have a temperature maintained <s>at</s> between 20˚C <s>to</s> and 21˚C.

#Public areas must be kept at a constant temperature between 23˚C and 25˚C.

#Air extracted from the mortuary may not be used for energy recovery or recirculation.

 

#REFRIGERATION EQUIPMENT DESIGN AND INSTALLATION

#All heat- rejection equipment associated with refrigeration in the body- storage facilities must be located on the outside of the mortuary, in a well-ventilated space at the rear of the fridge(s). Compressors installed on top of body cabinets on the inside of the mortuary are not acceptable. Heat build-up within the mortuary, as a result of this type of arrangement, potentially leads to equipment failure.

#Regularly serviced refrigeration equipment components should not be situated within the confines of the mortuary. Refrigeration technicians should not be required to climb onto or over a body cabinet to carry out any maintenance work. It is preferable to have refrigeration equipment situated in a separate ventilated area to the rear of the body cabinets. The designer is to refer to the selected heat- rejection equipment’s installation manual to determine free space and ventilation openings required around this equipment, since these details can vary between system types.

#Gauges indicating the temperature within the body cabinet must be clearly visible above the door of the unit in order that this can be readily monitored.

#The acceptable average temperature within a normal body cabinet or refrigerated room is between 2.0˚C and 6˚C. In instances where a body has to be kept for an extended period of time a cabinet temperature of at least -20˚C is required.

#In facilities where large quantities of bodies are kept, cold rooms for the storage of multiple bodies on trays are recommended.

#The materials used for the construction of the units are to be of stainless steel to facilitate cleaning and long-term maintenance of the equipment. Grade 316 stainless steel (18/10) is preferable over Grade 304 (18/8), as it offers better corrosion resistance'''.'''

#For welded stainless steel construction, Grade 316L or similar is required.

#If a facility is required to collect and retain forensic samples, refrigeration equipment should be provided for the preservation of these samples. Preferably this equipment should be placed in an area where <s>they</s> it can readily be secured from unauthorised access and tampering.

 

#SECURITY ARRANGEMENTS

#Due to the medical and legal nature of the contents of a mortuary, it is essential that a mortuary has good access control and security systems.

#Theft from mortuaries should be forestalled by, inter alia, constantly monitoring all entrances and preventing free access to mortuary areas. This is especially important for the body- storage areas. Access card or tag systems are open to misuse and are not an appropriate access- control measure. Combinations of tag and biometric access- control systems are recommended.

#Door closers with a “hold-open” mechanism should be installed on the mortuary room doors. This enables doors to close automatically with normal traffic, but can also be held open when moving equipment or trolleys through. “Crash”- type doors should be avoided as these are not easily cleanable and are subject to damage and abuse.

#It is recommended that a timed alarm be fitted to doors to ensure that they are closed shortly after any entrance or exit. This is to <s>mitigate</s> militate against the tendency of keeping doors open with some form of door stopper.

#Body cabinets are to be fitted with locks to prevent the unauthorised opening of these units to forestall the theft of any personal items of the deceased.

#In instances where historical problems relating to unauthorized entry into mortuaries is evident, it is recommended that closed-circuit TV systems be installed to help in monitoring and securing the facility.

PART C – Operation

#OBJECTIVES

The project planning, design, construction and commissioning should aim to provide:

#a safe, secure and functional environment for visitors and staff;

#low capital and ongoing operating costs (service, staffing and maintenance);

#an environmentally appropriate design solution; and

#a fully accessible, inclusive environment.

 

#HEALTH AND SAFETY

In light of the above it is essential that every effort be made to ensure that personnel working in the mortuary are provided with all required personal protective equipment (PPE), as this is essentially an area where pathogens could be present and present a health risk to staff. The following items should be available to staff as a minimum:

#Rubber aprons (or similar impervious material)

#Latex gloves (or similar impervious material)

#Mesh gloves in facilities where post mortems are performed

#Disposable gowns

#Safety glasses or full-face visors.

#Waterproof footwear

#Face masks

#Respirators with the appropriate filters must be available for use in high-risk situations.

#Storage space for PPE

No one should be permitted to enter the body storage and preparation areas without donning appropriate gowns and footwear.

#MAINTENANCE

When designing the facility, every effort must be made to limit the amount of maintenance that would be necessary to keep it in good condition. Seamless surfaces for walls and floors are critical, as this will reduce ongoing maintenance costs. The following minimum requirements should be complied with:

#Seamless floor coverings required

#Radiuses corners ??? required between floors and walls.

#No sharp corners on any work surfaces that could injure people working in the area.

#Ceilings to be readily cleanable.

#Work surfaces are to be impervious to liquids and resistant to staining and corrosion.

#Refer to the room- requirement sheets herein and the IUSS Materials and Finishes guidance documents for further information on the general requirements for materials and finishes.

#All equipment requiring calibration, such as fridges and scales, are to be attended to on an annual basis or when it is suspected that they are defective in respect of their expected/intended performance

PART D – User Room Requirements

Room-requirement sheets

Table 3: Accommodation schedule
{| class="wikitable"
|'''Room Name'''
|'''Service Description'''
 
|'''Area'''

'''(m²)'''
|'''Min. Ceiling Height'''

'''(m)'''
|'''Occupancy'''

'''(Persons)'''
|'''Nominal Utilisation per day'''

'''(hours)'''
|-
|Ablution areas
|Ablution areas – male and female

One WHB per WC or urinal
|3 (per cubicle)
|2.8
|1
|4
|-
|Shower facilities
|Shower facilities – male and female
|3 (per cubicle)
|2.8
|1
|2
|-
|Changing room
|Staff changing room - lockers to be provided
|8
|2.8
|2
|2
|-
|Storage space
|Equipment and PPE storage space
 
|8
|2.8
|1
|1
|-
|Offices
|Office space – interview, body receiving, pathologist
|9
|2.8
|2
|8
|-
|Body/bier room
|Area where a body can be laid out for viewing and identification
|9
|2.8
|1
|8
|-
|Viewing room
|Viewing room – external to body- layout area
|9
|2.8
|4
|1
|-
|Autopsy room
|Autopsy facility – Autopsy table with water supply and discharge and extraction ventilation. WHBs and stainless steel working surfaces
|27
|2.8
|3
|3
|}

'''Table 4: Room services sheet'''
 
{| class="wikitable"
|'''Room Name'''
|'''Temp'''

'''(°C)'''
|'''Ventilation'''

'''(AC/h)'''
|'''Ventilation'''

'''Type'''
|'''Pressure Relative to'''

'''Ambient'''
|'''Wet Services'''
|'''SSO'''

'''400V'''
|'''SSO'''

'''230V'''
|'''Task Illuminance'''

'''(lux)'''
|'''Data Points'''
|'''Colour Rendering'''

'''(Ra)'''
|-
|Reception area
|22-25°C
|2
|Forced supply
|=
|
|0
|0
|100 at floor level
|0
|80
|-
|Visitors ablution areas
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|WC,

WHB
|0
|0
|150 at floor level
|0
|80
|-
|Public waiting area
|22-25°C
|2
|Forced supply
|<nowiki>+ </nowiki>
|
|0
|0
|100 at floor level
|0
|80
|-
|Offices
|22-25°C
|2
|Forced supply/ recirc.
|=
|
|0
|2
|300 at desk level
|1
|80
|-
|Circulation Spaces
|22-25°C
|10
|Forced supply/ recirc.
|=
|
|0
|0
|200 at floor level
|0
|80
|-
|Viewing room
|22-25°C
|2
|Forced supply
|<nowiki>+ </nowiki>
|
|0
|0
|100 at floor level
|0
|80
|-
|Layout room
|20-21°C
|2
|Forced extraction
|<nowiki>- </nowiki>
|WHB
|0
|0
|300 at table level
|1
|80
|-
|Storage space
|22-25°C
|4
|Forced supply
|=
|
|0
|1
|200 at floor level
|0
|80
|-
|Mortuary
|20-21°C
|12
|Forced extraction
|<nowiki>- </nowiki>
|WHB,

FD
|0
|1
|200 at floor level
|0
|80
|-
|Mortuary plant area
|n/a
|n/a
|Natural ventilation
|=
|
|1
|1
|150 at floor level
|0
|80
|-
|Autopsy table
|20-21°C
|20
|Forced extraction
|<nowiki>- </nowiki>
|CW Faucet
|0
|1
|5200 at table level
|0
|90
|-
|Autopsy room
|20-21°C
|20
|Forced extraction
|<nowiki>- </nowiki>
|WHBs,

FD
|0
|2
|500 at floor level
|1
|90
|-
|Changing room
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|WHB
|0
|1
|150 at floor level
|0
|80
|-
|Staff ablution areas
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|WHB,

WC
|0
|0
|150 at floor level
|0
|80
|-
|Shower facilities
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|CW + HW

Faucet
|0
|0
|150 at floor level
|0
|80
|}

'''Table 5: Room finishes'''
 
{| class="wikitable"
|'''Room Name'''
|'''Floor'''

'''Material'''
|'''Wall / Floor Interface'''
|'''Walls'''

'''Finish'''
|'''Ceiling'''

'''Finish'''
|'''Glazing'''

'''Type'''
|'''WHB'''
|'''Doors'''

'''Type'''
|-
|Ablution areas (all)
|Jointless vinyl sheet
|Skirting coved and finished as per floor
|Ceramic wall tiles with epoxy grout
|Washable acrylic paint
|Obscure laminate safety glass
|1 per WC or urinal
|Solid wood with galvanised steel or stainless steel sheet trolley plates
|-
|Public waiting area
|Jointless vinyl sheet
|Coved vinyl skirting
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Lockable glazed entrance door
|-
|Changing room
|Jointless vinyl sheet
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Obscure laminate safety glass
|0
|Solid wood with galvanised steel or stainless steel sheet trolley plates
|-
|Storage space
|Jointless vinyl sheet
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood with galvanised steel or stainless steel sheet cladding
|-
|Offices
|Jointless vinyl sheet
|Coved vinyl skirting
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood
|-
|Body Room
|Self- levelling epoxy
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood
|-
|Viewing Room
|Self- levelling epoxy
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood
|-
|Autopsy Room
|Self- levelling epoxy
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Obscure laminate safety glass
|Min 1 per autopsy table
|Solid wood with galvanised steel or stainless steel sheet cladding
|-
|Circulation Spaces
|Jointless vinyl sheet
|Coved vinyl skirting
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|
|}
'''PART E – Examples and case studies'''

Figure 4 demonstrates the relationships between the zones within the mortuary. In this example it is evident how visitors are managed and kept out of the working portions of the mortuary through segregation in the internal layout. The process flow of the bodies into, through and out of the mortuary has been well considered in that the flow is linear with bodies entering the mortuary <s>on</s>at one end of the facility and exiting at the other. Unfortunately, the restrictions presented by the location of the mortuary, as can be studied in Figure 3, has forced the design into a number of compromises relating to the external flow and access to the mortuary. Staff access is quite severely compromised in being through the mortuary lobby. This mortuary lobby, in the absence of a dedicated preparation room, has the potential of being used as one. This arrangement may impact negatively on the dignity of some staff, the dignity of the deceased, and mortuary security.

Visitors’ access to the mortuary and their adjacent toilets is near the hearse bay and turning areas. There is no natural screening of this entrance from the activities in the hearse bay and it is not inconceivable that visitors may inadvertently wander into the wrong area and be exposed to operational activities not appropriate for the bereaved.

The door sizes of the body storage rooms seem too small for the easy passage of a body trolley when compared to the double doors made available for the passage of the body from there through the remainder of the facility. Door size selection should not be limited by the fact that these are cold room doors. Where doors are too small for free passage of trolleys and porters, <s>their</s> the doors’ service life would be severely shortened and any savings made on the door selection would be lost to maintenance or retrofitting an improved solution.

The access to the technical area for maintenance of the refrigeration equipment in this example meets the recommendations. Here technicians do not need to enter the mortuary to perform the majority of their work and these areas are quite well separated from the admin and visitors’ areas.

 

#EXAMPLE 2: LARGE MORTUARY WITH AUTOPSY FACILITIES

Figure 5 shows the layout of a standardised mortuary design. This is a large facility with autopsy capacity. Figure 6 has been presented in order to promote an understanding of the interrelationship between the various functional parts of the mortuary.

Considering the entrances shown in Figure 5, it is clear that the designer has <s>taken some</s>made an effort to screen the <s>visitor’s</s> visitors’ entrance from the hearses’ entrance. The staff entrance is also well positioned. The staff ablution<s>s</s> facilities and showers are located between the clinical areas and the admin areas. This arrangement encourages good segregation and gowning practice when moving between the mortuary activities and external movement.

The staff and visitors’ access positions are located well away from the working clinical areas of the mortuary and are also relatively remote from each other. This aids in improving security as it discourages the staff and visitors from using the wrong entrances and thereby assists in identifying persons who are present in areas where they do not belong.

This design doesn’t have a dedicated body prep area and it is assumed that the weighing and measuring area is therefore used for this purpose.

The large sliding doors of the cold room in this example can be compared to the cold-room doors in Figure 3 as an indication of what the door size should be like to enable easy passage.

The layout in this example does not provide for a dedicated exit yard and bodies and hearses entering and leaving the facility do so through the same entrance. This arrangement increases the potential for mistakes in body handling.

The common use of the bier room as access to the ID room seems to be a compromise resulting from the limited space provided for these rooms.

'''EXAMPLE 3: LARGE MORTUARY WITH AUTOPSY FACILITIES'''

The example shown in Figure 7<s>Figure 7</s> is a standard facility layout, very similar to that of Figure 5<s>Figure 5</s>, with the most notable changes being the inclusion of a dedicated vehicle- exit yard and the omission of the technical service area. The addition of the exit detail resolves the criticism of the arrangement in Example 2, while the omission of the technical service area for the refrigeration equipment could present an access problem for maintenance technicians, as discussed earlier in this document.

The example in Figure 7<s>Figure 7</s> has also resolved the compromises <s>to</s> in the arrangement of the bier rooms and ID/viewing rooms’ available space, discussed in the previous example.

'''DEFINITIONS'''

In the context of this document the following definitions pertain:
{| class="wikitable"
|'''Autopsy room:''' Synonymous with post–mortem examination area or suite.
|-
|'''Containment facility:''' The part within the demarcated zone in which the most malodorous activities occur. This facility includes the decomposing bodies’ post-mortem examination room, airlock ante room, and a decontamination unit each for men and women. The containment facility is sealed off from the rest of the demarcated area.
|-
|'''Demarcated area:''' The demarcated area, including the post-mortem examination rooms and all supporting functional spaces is the area where most sensitive, costly and specialised processes occur.
|-
|'''Dignity of deceased:''' The principle that bodies are treated with the respect and dignity befitting any person prior to death.
|-
|'''Dissection room or suite:''' Synonymous with post-mortem examination area or suite.
|-
|'''Mortuary:''' A mortuary is a facility for temporary storage of the deceased pending identification, medico-legal investigation and despatch.
|-
|'''Natural death:''' A death <s>by</s>from natural causes which <s>is</s> are determined to have been the cause of illness <s>of</s>or an internal malfunction of the body <s>which was</s> not caused by external forces.
|-
|'''Post-mortem examination area or suite''': A room and its attached service rooms designed for the performing of post-mortem examinations.
|-
|'''Post-mortem examination:''' Examination after death, which may include performance of an autopsy.
|-
|'''Unnatural death:''' A death which is not classified as being a '''''Natural Death'''''
|-
|'''Work bench (or bench):''' Unless otherwise specified, this is a surface ergonomically dimensioned for use from the standing position. This is normally 900mm.
|-
|'''Work-station:''' Unless otherwise specified, this is a surface ergonomically dimensioned for use from the seated position. This is normally 750mm. ??
|}

Page Break

'''BIBLIOGRAPHY'''

To be sorted out and made consistent - as advised to Mr Van Reenen
{| class="wikitable"
|REQUIREMENTS FOR THE FACILITIES AND OPERATION OF MORTUARIES (Second Edition 2009), NPAAC Tier 4 Standard. Australian Government Department of Health and Ageing.
|-
|MANAGING HEALTH AND SAFETY RISKS IN NEW ZEALAND MORTUARIES.(November 2000) Dr Chris Wells and Dr Jeff Brownless
|-
|Mortuary design and hazards. J. clin. Path. (1961), 14, 103
|-
|Health Authority Abu Dhabi. Part B- Version 3.1, June 2011
|-
|Design and layout of Mortuary Complex for a Medical College and Peripheral Hospitals. (2011) BasantLalSirohiwal, Paliwal PK, Luv Sharma and Hitesh Charlwa
|-
|Planning and design of modern mortuary complex in tertiary care. IIJFMT 4(1) 2006. Dr Sanju Singh, Dr U.S. Sinha, Dr A.K. Kapoor, Dr S.K. Verma, Dr Dalbir Singh, Dr Susheel Sharma
|-
|Australian Health Facility guidelines. Revision v.4.0 16-Dec-10
|-
|Mortuary Facilities – Design and improvement guide. CSIR March 2002
|-
|Project development brief for the new academic M6 pathology forensic laboratory. Western Cape Department of Health, August 2009
|-
|National Code of Guidelines for Forensic Pathology Practice in South Africa. Edited by NFPSC Academic Sub-committee 20 August 2007
|-
|IUSS Building Engineering Services guidance document
|}
{{Expand}}
[[Category:Procurement and Operation]]

Maintenance

2022-07-25T09:40:07Z

Tmojanaga: /* Contents */ text

Contents

OVERVIEW 5<s>6</s>

'''''Abbreviations''''' 9<s>8</s>

PART A – POLICY AND SERVICE CONTEXT 11<s>9</s>

Legislation, policies and international guidance 11<s>9</s>

1. LEGISLATIVE CONTEXT 11<s>9</s>

2. Further reference material and precedent<s>:</s> 11<s>9</s>

3. INFECTION PREVENTION AND CONTROL LEGISLATION 12<s>10</s>

4. BUILDING LEGISLATION 12<s>10</s>

5. SOUTH AFRICAN BUILDING PRACTICE POLICY AND GUIDELINES 12<s>10</s>

6. INTERNATIONAL DESIGN GUIDANCE 12<s>10</s>

Service Context 13<s>11</s>

PART B – PLANNING AND DESIGN 15<s>12</s>

1. INTRODUCTION 15<s>12</s>

2. LOCATION OF THE MORTUARY AND ACCESS ROUTES 16<s>13</s>

3. FACILITY CAPACITY 16<s>13</s>

4. SELECTING BODY STORAGE SYSTEMS 18<s>14</s>

5. FACILITY LAYOUT 18<s>15</s>

6. MORTUARY EQUIPMENT REQUIREMENTS 21<s>17</s>

7. MOVEMENT WITHIN A MORTUARY 22<s>18</s>

8. SERVICES REQUIRED 24<s>19</s>

9. BIOLOGICAL SAFETY 24<s>19</s>

10. FINISHES TO FLOORS AND WALLS 25<s>20</s>

11. AUTOPSY EQUIPMENT/FIXTURES 26<s>20</s>

12. VENTILATION 27<s>21</s>

13. AIR CONDITIONING 27<s>22</s>

14. REFRIGERATION EQUIPMENT DESIGN AND INSTALLATION 28<s>22</s>

15. SECURITY ARRANGEMENTS 28<s>22</s>

PART C – OPERATION 30<s>24</s>

1. OBJECTIVES 30<s>24</s>

2. HEALTH AND SAFETY 30<s>24</s>

3. MAINTENANCE 30<s>24</s>

PART D –USER ROOM REQUIREMENTS 32<s>32</s>

Room Requirement Sheets 32<s>32</s>

PART E – EXAMPLES AND CASE STUDIES 36<s>35</s>

Layout Examples 36<s>35</s>

1. EXAMPLE 1: SMALL MORTUARY ATTACHED TO HOSPITAL 38<s>36</s>

2. EXAMPLE 2: LARGE MORTUARY WITH AUTOPSY FACILITIES 39<s>37</s>

3. EXAMPLE 3: LARGE MORTUARY WITH AUTOPSY FACILITIES 43<s>40</s>

BIBLIOGRAPHY 46<s>42</s>

'''Table of Figures'''

Figure 1 Adjacency Diagram 1<s>16</s>

Figure 2: Access and Movement in a mortuary 1<s>18</s>

Figure 3 Example 1: Layout 1<s>35</s>

Figure 4 Example 1: Zoning & Access 1<s>36</s>

Figure 5 Example 2: Layout 1<s>38</s>

Figure 6 Example 2: Zoning and Access 1<s>39</s>

Figure 7 Example 3: Layout 1<s>40</s>

'''Table of Tables'''

Table 1 : IUSS Reference documents 8<s>7</s>

Table 2 Service Requirements 13<s>11</s>

Table 3 Accommodation Schedule 32<s>25</s>

TABLE 4 ROOM SERVICES SHEET 33<s>26</s>

TABLE 5 ROOM FINISHES 34<s>27</s>

''Version Control''
{| class="wikitable"
|''Template''
|''January 2013''
|''Tobias van Reenen''
|-
|''Discussion Draft 1''
|''February 2013''
|''Steve Fourie''
|-
|''Discussion Draft 5''
|''March 2013''
|''Steve Fourie''
|-
|''Discussion Draft 6''
|''May 2013''
|''Steve Fourie''
|-
|''Development Draft 1''
|''August 2013''
|''Tobias van Reenen''
|-
|''Development Draft 3.1''
|''February 2014''
|''Tobias van Reenen''
|-
|''Development Draft 3.1''
|''February 2014''
|''Prof J Vellema''
|}

Page Break

== '''OVERVIEW''' ==

This document outlines the policy and service context and attempts to illustrate the desired planning principles and design considerations for mortuary services.

* ''Part A'' outlines the South African legislation, policies and international guidance reference documents and the service context with respect to mortuary services;
* ''Part B'' Planning and design;
* ''Part C'' operation;
* ''Part D'' user room requirements; and
* ''Part E'' provides case studies.

Parts D and E are intended to demonstrate how the principles prescribed in Part A, B, and C can be applied in worked examples. Part D, if used directly, are deemed<s>-</s> to<s>-</s> satisfy the principles developed in Part B, but are not the only acceptable solutions.

Case studies (Part E) provide illustrative worked solutions and should not be adopted without appropriate contextual adaptation.

While this document outlines design requirements and acceptance criteria which have an impact on clinical services, these requirements are prescribed within the framework of the entire IUSS set of guidance documents and cannot be viewed in isolation. The following documents should be complied with, together with this document:

*IUSS: Regulations
*IUSS: Project Planning and Briefing
*IUSS: Environment and Sustainability
*IUSS: Hospital Design Principles
*IUSS: Infection Prevention and Control

Page Break

The following table identifies additional IUSS guideline documents which are recommended for reading in conjunction with this guideline.

=== '''Table 1 : IUSS Reference documents''' ===
{| class="wikitable"
|

'''CLINICAL'''

'''SERVICES'''
 
|Essential
|Recommended
|'''SUPPORT'''

'''SERVICES'''
|Essential
|Recommended
|'''HEALTHCARE ENVIRONMENT/ CROSSCUTTING ISSUES'''
|Essential
|Recommended
|'''PROCUREMENT'''

'''& OPERATION'''
|Essential
|Recommended
|-
|Adult Inpatient Services
|
|X
 
|Administration and Related Services
|
|
|Generic Room Requirements
|
|
|Integrated Infrastructure Planning
|
|
|-
|Clinical and Specialised Diagnostic Laboratory Guidelines
|
|X
|General Hospital Support Services
|
|X
|Hospital Design Principles
|
|
|Briefing Manual
|
|X
|-
|Mental Health
|
|
|Catering Services for Hospitals
|
|
|Building Engineering Services
|X
|
|Space Guidelines
|
|
|-
|Adult Critical Care
|
|
|Laundry and Linen Department
|
|X
|Environment and Sustainability
|
|
|Cost Guidelines
|
|
|-
|Emergency Centres
|
|
|Hospital Mortuary Services
|
|
|Materials and Finishes
|X
|
|Procurement
|
|
|-
|Maternity Care Facilities
|
|
|Nursing Education Institutions
|
|
|Future Healthcare Environments
|
|X
|Commissioning Health Facilities
|X
|
|-
|Adult Oncology Facilities
|
|
|Health Facility Residential
|
|
|Healthcare Technology
|
|
|Maintenance
|X
|
|-
|Outpatient Facilities
|
|X
|Central Sterile Service Department
|
|
|Inclusive Environments
|
|
|Decommissioning
|X
|
|-
|Paediatrics and Neonatal Facilities
|
|
|Training and Resource Centre
|
|X
|Infection Preventive Control
|X
|
|Capacity Development
|
|
|-
|Pharmacy
|
|
|Waste Disposal
|
|X
|Health Informatics
|
|
|
|
|
|-
|Primary Health Care Clinics and CHCs
|
|
|
|
|
|Regulations
|
|
|
|
|
|-
|Diagnostic Radiology
|
|
|
|
|
|
|
|
|
|
|
|-
|Adult Physical Rehabilitation
|
|
|
|
|
|
|
|
|
|
|
|-
|Sub-acute services
|
|
|
|
|
|
|
|
|
|
|
|-
|Facilities for Surgical Procedures
|
|
|
|
|
|
|
|
|
|
|
|-
|TB Services
|
|
|
|
|
|
|
|
|
|
|
|}

'''''Abbreviations'''''
{| class="wikitable"
|ACH
|Air changes per hour
|-
|ASHRAE
|American Society of Heating, Refrigerating, and Air-Conditioning Engineers
|-
|BMS
|Building Management System
|-
|BSL
|Biological safety level
|-
|CDC
|Centers for Disease Control (USA)
|-
|CSIR
|Council for Scientific and Industrial Research
|-
|FD
|Floor drain
|-
|FPS
|Forensic Pathology Service
|-
|HVAC
|Heating Ventilation Air Conditioning
|-
|HBA
|Hazardous biological agents
|-
|HCS
|Hazardous chemical substances
|-
|HEPA
|High efficiency particulate air filters
|-
|IPC
|Infection prevention and control
|-
|ISO
|International Standards Organisation
|-
|MDR TB
|Multi-drug resistant TB
|-
|NDoH
|National Department of Health
|-
|NBR
|National Building Regulations
|-
|<s>NDoH</s>
|<s>National Department of Health</s>
|-
|NHS
|National Health Service (UK health service)
|-
|NIOSH
|National Institute of Occupational Safety and Health (US agency)
|-
|O&M
|Operating and Maintenance (manual)
|-
|OHS
|Occupational health and safety
|-
|OQ
|Operational qualification
|-
|PGWCDoH
|Provincial Government Western Cape Department of Health
|-
|PPE
|Personal protective equipment
|-
|PQ
|Performance qualification
|-
|RDS
|Room data sheets
|-
|RH
|Relative humidity
|-
|SABS
|South African Bureau of Standards
|-
|SAO
|Senior Administrative Officer
|-
|SAPS
|South African Police Service
|-
|SI
|<s>Le Systeme International d' Unites</s> Le Système International d’Unités
|-
|SOP
|Standard Operating Procedures
|-
|SS
|Stainless steel
|-
|TB
|Tuberculosis
|-
|WC
|Toilet
|-
|WHB
|Wash-hand basin
|-
|WHO
|World Health Organisation
|-
|XDR TB
|Extreme (or extensively) <s>-</s>drug- resistant TB
|-
|
|
|-
|
|
|-
|
|
|}
PART A – Policy and service context

Legislation, policies and international guidance
 

=== LEGISLATIVE CONTEXT ===
The following documents, as amended (though not an exhaustive list) pertain and contain an additional resource of information which would supplement and provide the basis of a design brief. A finer sense of standard operating procedures and legislative context is likely to inform and enhance the design process, so the professional teams are encouraged to use these as an additional resource:
 

*Inquest Act<s>,</s> 58, 1959
*National Health Act<s>,</s> 61, 2003
*Government Notice R363, 2013 [Regulations relating to the management of human remains]
*Government Notice R178, 2012 [Regulations relating to the registration of microbiological laboratories and the acquisition, importation, handling, maintenance and supply of human pathogens]

*Health Professions Amendment Act, 29, 2007
*Criminal Procedures Act<s>,</s> 51, 1977
*Births and Deaths Registration Act<s>,</s> 51, 1992
*National Environmental Management: Waste Act<s>,</s> 59, 2008
*National Archives of South Africa Act<s>,</s> 42, 1996

*Regulations regarding the Rendering of Forensic Pathology Service, ''Government Gazette'' No 30075. No R636, 20 July 2007
*Space Planning Norms and Standards for Office Accommodation used by Organs of State, ''Government Gazette'' No 27985. No 1665, 2 Sept 2005
*Western Cape Health Care Waste Management Draft Bill
*Municipal by<s>-</s>laws, as applicable
*National Code of Guidelines for Forensic Pathology Practice in South Africa, 20 Aug 2007

*Standard Operating Procedures, Forensic Pathology Service, PGWCDoH, 2006
*Biosafety in Microbiological and Biomedical Laboratories, U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention and National Institutes of Health, Fifth Edition, <s>2007</s> US Government Printing Office, Washington: 2007

 

#Further reference material and precedent<s>:</s>

 

*Standard specification for air-conditioning and ventilation systems, Western Cape Department of Public Works, 1998
*Fire security: a guide for architects, Western Cape Department of Public Works, 1998
*Standard electrical specification, South African Department of Public Works, 2005
*Facilities for mortuary and post-mortem room services, NHS Estates, 2001, ISBN 0-11-322000-00
*Part B – Health facility briefing and planning, Australasian Health Facilities Guidelines, 2007

*CKS 336: 2013 Mortuary Trolleys - SABS

#INFECTION PREVENTION AND CONTROL LEGISLATION

The National Infection Prevention and Control Policy and Strategy document makes specific reference to certain Acts and their relevant regulations, which bear relevance to the development and implementation of these health facility guidelines. These are:

*The South African Constitution, 1996 [Sections 2, 24, 27, 36 and 39], as amended
*The Occupational Health and Safety Act of 1993, Act No 85 of 1993 [Section 8(1)]

*Government notice R1390 of 27 December 2001 [Hazardous Biological Agents Regulation] as promulgated under Section 43 of the Occupational Health and Safety Act of 1993
*Government notice R908 of 27 June 2003 [Hazard Analysis Critical Control Point Regulation] as promulgated under Section 15(1) of the Foodstuffs, Cosmetic and Disinfectants Act of 1972
*The Environmental Conservation Act of 1989, Act No 73 of 1989
*The Foodstuffs, Cosmetic and Disinfectants Act of 1972, Act No 45 of 1972

 

#BUILDING LEGISLATION

The following legislation and regulations impact and provide guidance on the provision and design of health care facilities as above:

*The National Environmental Management Act 107 of 1998, as amended
*Building regulations and Building Standards Act 103 of 1977, as amended
*National Building Regulations; SANS 10400:2010, Code of Practice for the Application of the National Building Regulations

*Promotion of Equality and Prevention of Unfair Discrimination Act No 4 of 2000
*General Procedures and Loadings adopted in the Design of Buildings, SABS 0160, 1993
*Structural Use of Concrete Design, SABS 0100-1, 1992
*Structural Use of Concrete – Materials and Execution of Work, SABS 0100-2, 1992
*Specification for Civil Engineering Construction SABS 1200

 

#SOUTH AFRICAN BUILDING PRACTICE POLICY AND GUIDELINES

*R158 of 1980 regulations pertaining to Private Hospitals and Unattached Operating Theatres – R198
*Good Pharmacy Practice, Board Notice 129 of 2004, as amended [see Chapter 1].

#INTERNATIONAL DESIGN GUIDANCE

*ASHRAE Standard 52.2, “Method of Testing General Ventilation Air-Cleaning Devices for Removal Efficiency by Particle Size”, 1992, 1999b
*ASHRAE Standard 62, “Ventilation for Acceptable Indoor Air Quality”, 1989
*ASHRAE. “HVAC Design Manual for Hospitals and Clinics, 2003”, 1989
*CIBSE Applications Manual AM10:1997 “Natural Ventilation in Non-Domestic Buildings”, 1998
*CIBSE Applications Manual AM13:2000 “Mixed Mode Ventilation,” 2000

*ASHRAE Standard 170, “Ventilation of Health Care Facilities”, 2008
*QASA. “Know Your Rights” [Accessibility & the Built Environment]
*Department of Health and Human Services. “Environmental Control for Tuberculosis: Basic Upper-Room Ultraviolet Germicidal Irradiation - Guidelines for Healthcare Settings”, 2009
*WHO. “WHO Policy on TB Infection Control in Health-Care Facilities, Congregate Settings and Households”, 2009

Guidance has also been provided by AIA (USA), NHS (UK), and Australian Health Facility Guidelines on Healthcare Building Design. Additional references can be sourced from www.tb-ipcp.co.za

Service Context

The following table gives an indication of the service requirements for mortuaries within different types of public hospitals.

Table 2: Service Requirements
{| class="wikitable"
|'''Service'''
|'''District'''
|'''Regional'''
|'''Tertiary'''
|'''Central'''
|'''Specialised'''
|-
|Small (beds)
|50-150
|Min 300
|Min 400
|
|
|-
|Medium (beds)
|150-300
|
|
|
|
|-
|Large (beds)
|300-600
|Max 800
|Max 800
|Max 1200
|Max 600
|-
|Training
|Where practical
|Where practical
|Optional
|Yes. Attached to medical school
|
|-
|Conduct research
|
|
|
|Yes
|
|-
|'''Mortuary'''
|
|
|
|
|
|-
|Short-term stay (2˚C)
|Yes
|Yes
|Yes
|Yes
|
|-
|Long-term stay (-15˚C)
|Yes
|Yes
|Yes
|Yes
|
|-
|Autopsies (20°C -21°C)
|Yes
|Yes
|Yes
|Yes
|Yes
|}

For the determination of capacity requirements of mortuaries refer to the recommendations further on in this document.

This guidance document relates to mortuaries located within and serving hospitals, with respect to persons that die due to natural causes in that hospital. This document excludes mortuaries <s>exclusively</s> dealing exclusively with cases that require medico-legal investigation of deaths from unnatural causes.

Post mortems conducted in hospital mortuaries should be limited to conducting investigations and procedures where no medico-legal investigation is required and death from natural causes is suspected.

Hospital deaths from natural causes and those suspected to be of unnatural cases should not be managed in the same facility unless the hospital mortuary is equipped to comply with the specific legal requirements as <s>it</s> they relate<s>s</s> to the chain of evidence, etc. The requirements for forensic- pathology service mortuaries are not exhaustively detailed in this document.

It is also noted that some hospitals may opt to contract out the removal and storage of decedents to private undertakers and these hospitals may <s>only</s> require only the minimum in terms of refrigerated body storage.

PART B – Planning and Design

#INTRODUCTION

#All state- run mortuary facilities fall within the domain of the Department of Health, both National and Provincial;<s>,</s> and in an effort to provide engineers and architects who are required to either design new facilities or upgrade existing facilities, this document provides the minimum standards necessary to comply with existing legislation.

#This document will provide designers of this type of facility with guidelines as to what is required in terms of the following:

*Type of service and package of care being provided
*Mortality rate
*Access and egress
*Discreet management of human remains

*Size and dimensions of the actual facility
*Positioning of mortuaries within hospitals
*Finishes of surfaces in these facilities
*Water- supply requirements
*Drainage requirements

*Electrical supply and lighting requirements
*Installation requirements for equipment and services
*Body-storage requirements
*Body-handling facilities
*Body-holding areas

*Body-viewing area
*Autopsy equipment (tables)
*Air conditioning and ventilation requirements (for infection and indoor air quality control)
*Security of the facility

#In addition to the items listed above, it is also necessary to consider the needs of visitors to these facilities, particularly those wishing to, or who are required to, identify bodies. In line with this it is also necessary to take the handling of bodies into consideration as it pertains to issues of patient dignity.

#Forensic pathology mortuaries are not <s>considered</s> exhaustively described in this document, although the majority of mortuaries do have basic facilities for general autopsies that are not necessarily medico-legal in nature. A forensic pathology mortuary has laboratory facilities attached that are outside the scope of regular mortuaries found in hospitals and at police stations. It should be noted that there are a number of principles that hold true for both hospital and forensic pathology mortuaries.

#Compliance with the requirements of the Occupational Health and Safety Act (Act 85 of 1993 as amended) are to be complied with at all times during the design of a mortuary.

 

#LOCATION OF THE MORTUARY AND ACCESS ROUTES

#The position of the mortuary in a hospital should be such that the mortuary is easily accessible to mortuary staff and related service providers without presenting either aesthetic, emotional or ethical problems for unrelated hospital staff, patients or visitors. Visitors to the mortuary, however, should be provided with clear and direct access to the mortuary upon arrival at the hospital, without having to travel unnecessarily through hospital departments.

#Where bodies are moved into or out of the mortuary, they should not be moved through general public-access areas. Appropriate routes would include technical service or goods corridors and through the hospital’s support services yard.

#Special considerations should be given to plans for contingency access to the mortuary in the event of case- load surges, which may <s>be</s> result from disasters.

#Bodies should not be held for any period in any locations between the body- holding rooms within clinical areas and the mortuary.

#Where a mortuary unit is used jointly between the hospital and the local authority it is beneficial for the mortuary to be in a building separate from the main hospital building.

#The delivery of bodies to the mortuary and their subsequent removal from the facility is to be such that it is carried out in a manner that is not visible to the general public, preferably in a covered and enclosed area.

#While siting and access are important aspects when locating a mortuary, it is also important to provide the mortuary with pleasant surroundings in order to promote the dignity of those working in or visiting the mortuary.

 

#FACILITY CAPACITY

#The layout and size of a mortuary is largely determined by the number of bodies stored and whether body storage needs to be in cabinets or in refrigerated rooms.

#In order to determine the storage capacity of a hospital mortuary it is recommended that historical data, where available, should be used. In the South African context it is suggested that a storage capacity of between 5 and 10 bodies per 100 beds should be used. This varies with the rural or urban location of the facility. This capacity should not take into account the need to store bodies from deaths which are not hospital related, typically motor-vehicle accident deaths and deaths from criminal activity. Requirements for contingency storage capacity related to disaster management should be considered.

#The body storage capacity required can be estimated on the basis of the number of deaths per year in the hospital, the length of time of holding and the required body store occupancy rate. The number of body trays can be calculated from Equation 1<s>Equation 1</s> below.

-Equation 1

Where:

BT = Number of body trays

D = Number of deaths per year requiring body trays

S = Average length of stay (in days)

R = Required body tray occupancy rate

[Text Box]

#The estimated storage capacity for bodies in a mortuary could be confounded by a number of local factors, such as:

*Mortality rate from natural causes.
*Mortality rate from infectious disease. (Highly contagious disease deaths require special storage facilities.)

#Where the hospital is expected to place the body in cold storage until collection by forensic pathology services the following additional factors should be considered:

*Mortality rate from foul play.
*Mortality rate from traffic incidents.

 

#SELECTING BODY-STORAGE SYSTEMS

#Body-storage systems are principally divided into refrigerated rooms or body cabinets. Differences within these system types occur where specific temperatures or sizes are required based on risk, need and capacity requirements.

#Where a system of functionally separate body cabinets is selected, this system would have an inherent redundancy against failure, as the failure of a single unit would not necessarily imply a system failure. In contrast, a refrigerated room would require less maintenance and would have a lower frequency of failure; however a single component failure could be critical if standby condensing units are not installed. For this reason, multiple- cabinet systems are recommended for areas where expected maintenance response times would negatively affect the mortuary’s operations.

#It is possible to have a requirement for a mixture of refrigerated rooms and body cabinets. This could be affected by local cultural requirements such as for families <s>which</s> who object to bodies sharing storage space, the case load of the facility or the case profile.

#Where there is a requirement for the long-term storage of bodies, these are to be kept at a lower temperature than would be the case in a refrigerated room. In this instance separate body cabinets are required. Long- term storage of bodies is most often required when an indigent person dies and difficulty is experienced in locating the next of kin, as the person cannot legally be buried until this process has been completed.

#In general, smaller facilities rely on body cabinets for the storage as these facilities do not have the space or the need for the large-scale storage of bodies, <s>and they do not</s>they would not appreciate the functional flexibility offered by these systems. By rule of thumb, any facility that has the requirement to store <s>less</s> fewer than 12 bodies at any given time should use body cabinets. This <s>provides</s> gives the option of providing both short- and long-term storage with the smallest facility and equipment footprint.

#Bodies suspected of having succumbed to a highly contagious and dangerous disease require special treatment. These should be stored in such a manner that they do not present a hazard to personnel working in the mortuary. Typically these bodies should be stored at the same temperature<s>s</s> <s>the same</s> as <s>for</s> long- stay bodies, e.g. -15˚C, and should be placed in hermetically sealed plastic body-bags.

#Provision for the secure cold storage of body parts should <s>also</s> be provided.

 

#FACILITY LAYOUT

#As mentioned, the layout and size of a mortuary is going to be largely determined by case load and whether storage is in cabinets or refrigerated rooms. It is acceptable to have a mixture of refrigerated rooms and body cabinets.

#In a mortuary facility there are a number of separate areas that need to be considered other than the body- storage areas. These include:

#'''Reception area''' for members of the public who are required to visit the mortuary on official business – typically to identify bodies or to pay their last respects to a deceased person.

#'''Ablution areas''' for staff. Where unisex ablutions are provided it is recommended that <s>the</s> no urinal is provided.

#<s>'''Visitor’s'''</s> '''Visitors’ admin space''' close to the reception area, where any admin or official business related to the identifying of a body can be completed.

#'''Staff admin space''' close to the point where a body is delivered to the mortuary, so that pertinent documentation can be completed – both with respect to the delivery of the body, as well as when the body is released from the mortuary again.

#'''Office space''' for pathologists to write up reports <s>for</s> in instances where this could be required. This is dependent on the size of the mortuary as small facilities would not require a separate room(s) for this function.

#'''Waiting''' and circulation areas for visitors to the mortuary.

#'''Viewing room,''' from where a body can be viewed through a curtained glass window between this space and the body- display room.

#'''Body- display''' room, where a body is placed for identification purposes. There is to be access to this area via a lockable door to the viewing room <s>for</s> in instances where it is necessary for non-mortuary personnel to have direct access to a body in the viewing room. There is to be access to this room from the body- storage area to allow bodies to be brought in for display purposes.

#'''Body preparation''' area, where a body that is delivered to the mortuary needs to be attended to prior to it being placed in the viewing room.

#'''Shower facilities''' (staff)

#'''Changing room''' (staff)

#'''Storage space''' for equipment and clothing that is worn in the body-preparation and autopsy spaces.

#'''Body-storage''' facility (cold room or refrigerated cabinets), depending on the length of time that bodies are expected to be kept in the facility.

#'''Autopsy facility,''' where the cause of death can be determined. This facility will differ from mortuary to mortuary, depending on whether forensic or standard medical autopsies to determine the cause of death are conducted.

[GroupDrawing]
 

#Figure 1<s>Figure 1</s> is an example of an adjacency diagram for a typical mortuary. In this instance the proximity also relates to visual and physical access. It is also understood that not all mortuaries would require all of the spaces indicated in this diagram, and that some of the spaces shown as being '''''immediately adjacent''''' could be included as a single area if functionality and privacy considerations permit it.

#There remains abundant scope for variations in the planning of the layouts making up the mortuary. and the hospital architect should consult with all stakeholders to arrive at an ideal solution.

#When developing the facility layout, careful consideration should be given to the routes through the facility of staff, bodies and visitors. These routes should overlap as little as possible and there should never be a common entrance for bodies and staff or visitors.

#The room requirement sheets are presented in ''PART D – User Room Requirements<s>PART D –User Room Requirements</s>''of this document.

#Storage space for body lifts must be provided.

#Suitable sluicing facilities are required to be able to clean equipment and fabrics after completion of any work in the mortuary facility.

 

#MORTUARY EQUIPMENT REQUIREMENTS

#Equipment for storage and transportation of bodies should meet environmental hygiene standards.

#For mortuary trolley design and supply, the SABS published standard '''''CKS336:2013 Mortuary Trolleys''''' is recommended. It should be noted that this is not a normative South African National Standard, and individual requirements may differ.

#'''Body-cabinet''' selection and installation requires the following considerations:

#Three-level body cabinets could be selected which have a single door to give access to all of the body trays, for instances where separation between bodies is required. Alternatively, cabinets that provide a single door for access to all the body trays are acceptable.

#It is critical that bariatric (obese) bodies are catered for in each cabinet. The lowest-level tray should be designed for this purpose.

#Special consideration is to be given to the provision of capacity for storage of juvenile and infant decedents. The handling of these bodies is an especially sensitive and emotive issue, and separate storage in dedicated cabinets is recommended.

#Body lifts must be supplied to facilitate the loading of bodies into and removal of bodies from the cabinets. Body lifts help to preserve dignity when handling bodies, while at the same time making it easier and safer for mortuary personnel to handle bodies.

#A clear space must be provided in front of the body cabinets to allow for the placing of a corpse into the cabinets. It is recommended that there be at least a 3m clearance between the front of the cabinet and any fixed structure. This is to accommodate whatever means of conveyance is used to transport a corpse to ?? and then load it into the cabinet.

#Due to the vast array of cabinets available on the market and the lack of an appropriate national standard, it is not yet possible to prescribe sizes for refrigerated cabinets in this guide.

#The required cabinet size is fundamental when designing a mortuary. Where space is not too limited and there are no indications that there may be cultural concerns relating to the storage of bodies together in a cold room, it is recommended that cold rooms be used. Cold rooms offer space savings when compared to cabinets.

#A temperature gauge must be installed close to the door of the facility to indicate the storage-space temperature. This gauge should have an alarm system connected to it to give a warning should there be an unacceptable rise in temperature in the storage space. Typically, if the temperature should rise more than 2˚C above the set temperature, an alarm should be activated at a point that is manned at all times.

#Body cabinets and refrigerated rooms must be supplied with electrical power from the hospital’s essential services electrical supply.

#A slop hopper is to be provided to allow for the cleaning of the body preparation and autopsy areas, in particular after the completion of any work carried out in these areas.

#To allow for the rinsing of body parts and organs, during an autopsy procedure it is important that suitable basins be provided in close proximity to <s>the</s>a downdraft autopsy table.

#Where there is transition between “clean” and “dirty” areas, provision is to be made to allow for the cleaning of footwear in a “transitional” area. This helps prevent the transport of contaminants from dirty areas.

 

#MOVEMENT WITHIN A MORTUARY

#Movement of members of the public visiting the mortuary is to be restricted such that they do not have access to the body- preparation or autopsy areas. (Figure 2<s>Figure 2</s>)

#The facility must be available within the mortuary where body identification can be conducted in a private and dignified manner. This viewing area should consist of a body- display or layout room with an adjacent viewing room, where the body can be viewed through a curtained shatter-proof glass window.

#The requirement for a viewing and identification area also pertains to hospitals which outsource their mortuary services.

#The viewing room and visitors’ admin rooms should be designed such that counselling can be conducted in a pleasant environment for bereaved persons.

#The design of the viewing facility should allow <s>for</s> adequate space for persons to view a body in a dignified manner.

#Direct access to the body- layout room from the viewing room is to be provided via a lockable door, to allow visitors access to the body.

#Ablution facilities are to be available to members of the public who are required to visit the mortuary complex.

#[GroupDrawing]Where a dedicated room, as described above, cannot be allocated for placing a body for viewing purposes, the persons who are viewing a body should be given a private space for viewing the body through a curtained shatter-proof glass window, as a minimum.

#Adequate facilities to accommodate at least 7 visitors are to be provided.

#Staff access to the mortuary facility is to be separate from the general public. (Figure 2)

#Mortuary staff change rooms should be provided with secure lockers for storage of street garments, lab coats, personal protective equipment and valuables. <s>Street garments and lab garments</s>

#Mortuary staff may have completely separate ablution facilities from those used by the general public requiring access to the mortuary facility.

#In a free- standing mortuary building the delivery to and removal of bodies from the facility may be via the same access point to the building.

#A mortuary that forms an integral part of a hospital will require separate routes for receiving bodies and the subsequent removal thereof.

#In the unusual event that a body arrives from outside <s>of</s> the hospital, the normal route of removal should be used for receipt of the body.

#A clear distinction is to be made between “clean”,” “dirty” / “wet” and “transitional” areas. This is best achieved by creating a physical “RED LINE” on the floor indicating the separation of these areas, with “yellow lines” used to demarcate “transitional” areas. Receptacles for the collections of dirty clothing, etc, must be made available at the transition area from <s>a</s> dirty to clean areas and in change rooms.

#A well-drained facility for washing <s>of</s> vehicles which have been contaminated with decomposed bodies or <s>bodily</s> body fluids should be provided in an enclosed area, near to the mortuary.

 

#SERVICES REQUIRED

#Hygienic floor drains that are resistant to corrosion from blood and chlorine should be provided in all “wet areas” of the mortuary and should be directly connected to the sewer system. These areas include body preparation, autopsy space, etc. These areas require thorough cleaning after every procedure, using large quantities of water and decontaminating and disinfecting chemicals and soaps.<s>.</s>

#Sluicing facilities are to be provided in both the body- preparation and autopsy areas if they are not a common area.

#Open floor channels should be avoided. Where this is not possible, these should be covered by durable, flush- fitted stainless steel grids.

#No sewer connections external to the mortuary services should be made to the line between the wet area drains and the main sewer system in order to prevent backflow to other areas.

#The provision of hot and cold water in the facility is imperative, with all basins, sinks, ablution areas and autopsy tables being provided with both.

#Anti-backflow devices should be fitted to the water- supply lines serving mortuary table faucets to prevent backflow should supply water pressure fail.

#Electricity supply to the mortuary – particularly for refrigeration purposes – is to be provided from the essential supply system for the hospital. Alternatively, a back-up generator is to be supplied to allow for the maintenance of required temperatures in the cooling/freezing facilities in the mortuary.

 

#BIOLOGICAL SAFETY

#A Biosafety Laboratory Level 3 (BSL3) designation (R178-2012) is applicable for any decomposing bodies post-mortem area. This area is identified as a level-3 containment facility.

#BSL3 areas shall have restricted access and shall be separated from regular traffic flow routes.

#All doors opening into the BSL3 areas shall be appropriately labelled with biological safety hazard signage.

#Access to the BSL3 areas shall be through dedicated ventilated airlocks. A pressure differential of minimum +15Pa shall be maintained for the airlock relative to the BSL3 area. This pressure differential is relevant for when the doors are closed only. Room pressure differential gauges are to be fitted at the entrance to the BSL3 area.

#Airlock doors shall be interlocked such that only one door can be opened at a time, thereby preventing direct passage between the corridor and the BSL3 area.

#It is recommended <s>to create</s>that a transfer hatch be created for the transfer of goods between areas with differing biosafety-level classifications. This device shall be designed to preserve the integrity of the containment system and the mechanical ventilation design.

#Air exhausted from biosafety areas should be safely discharged to the outside with no chance for re-entrainment or contamination of other indoor spaces. Exhausts from biosafety areas should be vented at 3m above the roof level. Where such measures are not possible, exhaust air shall be EN1822 H13 HEPA filtered. Exhausts from biosafety areas should include anti-backflow devices.

 

#FINISHES TO FLOORS AND WALLS

#Walls and floor coverings within a mortuary should be easily cleanable and impervious to liquids and staining.

#Floors are to be of such a nature that they are not easily damaged by wheeled items that are moved over them. Vinyl floor coverings are not considered to be resilient enough for this purpose.

#Epoxy floor coverings are preferable, as these are easily maintained and do not have joints in them where liquids can accumulate to become a health risk.

#Corners between walls and floors shall be coved to facilitate the cleaning of these areas. These coving details should be solid and continuous without hidden formwork and cavities.

#Walls are to be coated with hard- wearing and washable materials/paint with provision made for trolley “bumpers” along walls exposed to high traffic. Wall coatings shall be impervious to damage from trolleys and mobile equipment.

#Materials such as vinyl sheeting should not be used to cover walls in wet areas. The risk of growth between the sheeting and the wall presents a health hazard to personnel working in the mortuary wet areas.

#Due to the potential presence of water on flooring it is essential that flooring be non-slip.

#Refer to the room requirement sheets herein and the '''''IUSS Materials and Finishes''''' guidance documents for further information.

#Surface- mounted services should be avoided to ensure smooth and washable surfaces. Where surface mounting of piping is unavoidable, this piping should be mounted on batons, such that the space behind the piping is readily accessible for cleaning.

 

#AUTOPSY EQUIPMENT/FIXTURES

#Equipment for the storage and transportation of bodies should meet environmental hygiene standards.

#In the majority of instances a<s>n</s> downdraft autopsy table is required within a hospital mortuary facility. This table should be one that is designed in such a way that there is a hot and cold water supply that is integral to table installation, as well as a drainage system that can automatically drain water/waste from the table to the sewer system of the facility.

#The autopsy table should have an integrated ventilation extraction or “downdraft” system in order to entrain noxious odours and infectious material that may emanate from a body. This can function to minimise the spread of any airborne pathogens from the body.

#Adequate stainless steel washing basins (at least one per autopsy table) must be provided in close proximity to the autopsy table for the use of personnel working in the facility.

#Electrical power must be provided from a 5 amp IPX5 waterproof single-socket outlet near the autopsy table to allow for the safe use of any electrical equipment that may be required during an autopsy.

#Lighting quality over the autopsy table must be exceptionally good. Refer to the lighting requirements specified in the room- requirement sheets herein and the '''''IUSS Building Engineering Services''''' guidance document for specifications.

#Adequately sized worktops must be provided along the walls of the autopsy area for equipment and specimens prior to storage.

#It is recommended that working surfaces of at least 500x2500mm be provided per autopsy table.

#A balance table for a bench-top scale is required. The scale can be either permanently mounted on the work surface or stored in the autopsy equipment store.

#A platform scale for measuring the weight of an entire body prior to any possible dissection/autopsy work being conducted is to be accommodated.

#Lockable <s>C</s>cabinets are required for the storage of autopsy equipment, as well as for any personal protective equipment morticians or medical examiners may require.

#Trolleys for the conveyance of bodies must be provided in the mortuary and adequate provision for the storage of these units must be available.

#The use of wood, such as for wooden doorframes, is not allowed in wet areas.

#Stainless steel bump rails or plates should be fitted in areas prone to damage from trolleys. These devices shall be fitted such that that they do not affect the integrity and cleanability of the walls and floors. These devices shall not create crevices or gaps which could <s>would</s> harbour pathogens or create a hygiene problem. Welded stainless steel sections shall be stainless steel Grade 316L

 

#VENTILATION

#<s>Mortuaries</s> Mortuary areas require good ventilation. The exhaust air is to be discharged to atmosphere such that it cannot be drawn back into the mortuary, any other ventilation inlet, or any indoor portion of the hospital.

#All external ventilation openings should be fly- and vermin- proof.

#Exhausted air may not pose a hazard to any person who is outside the mortuary. (See room-requirement sheets) Air exhausted from clinical areas should be safely discharged to outside with no chance for re-entrainment or contamination of other indoor spaces. Where these precautions are by no means possible, exhaust air shall be EN1822 H13 HEPA filtered.

#Sufficient ventilation is required for controlling noxious odours present in mortuaries and should also provide a means of protection to personnel working in the facility from possible airborne infections originating from corpses.

#Airborne- infection control is of particular concern and must be designed for in terms of the ventilation system. Tuberculosis, Hepatitis and HIV are <s>of</s> among the most regularly encountered diseases in mortuaries in South Africa and, as such, the spread of these pathogens beyond the mortuary, via a ventilation system, must be avoided by implementing the airborne- contamination control principles for high- risk areas in the ventilation system design. Refer to the '''''IUSS Building Engineering Services''''' guidance document for further guidance on airborne- contamination control principles.

#The ventilation system must be designed such that airborne pathogens that may be present in the body- holding area and autopsy room do not contaminate the remainder of the mortuary facility.

#No recirculation of air extracted from the clinical areas is permitted.

#Air from public areas, with the exception of viewing rooms, may be recirculated where this is in accordance with the National Building Regulations.

#Exhaust ventilation is to be designed in such a manner that this extracts from the areas with the highest risk of infection, while “clean” air is to be supplied into the lower- risk areas. This is to create a pressure cascade with cleaner areas being at a relatively higher air pressure than dirty areas.

#Air- supply registers should be at a high level and the extraction registers should be at a low level. The low- level extraction grilles shall not be more than 500mm above the finished floor level of the room <s>where</s> from which the extraction is taken <s>from</s>. Low- level air- register positions shall consider locations of water points and potential splashing during washing.

 

#AIR CONDITIONING

#The mortuary and autopsy area must have a temperature maintained <s>at</s> between 20˚C <s>to</s> and 21˚C.

#Public areas must be kept at a constant temperature between 23˚C and 25˚C.

#Air extracted from the mortuary may not be used for energy recovery or recirculation.

 

#REFRIGERATION EQUIPMENT DESIGN AND INSTALLATION

#All heat- rejection equipment associated with refrigeration in the body- storage facilities must be located on the outside of the mortuary, in a well-ventilated space at the rear of the fridge(s). Compressors installed on top of body cabinets on the inside of the mortuary are not acceptable. Heat build-up within the mortuary, as a result of this type of arrangement, potentially leads to equipment failure.

#Regularly serviced refrigeration equipment components should not be situated within the confines of the mortuary. Refrigeration technicians should not be required to climb onto or over a body cabinet to carry out any maintenance work. It is preferable to have refrigeration equipment situated in a separate ventilated area to the rear of the body cabinets. The designer is to refer to the selected heat- rejection equipment’s installation manual to determine free space and ventilation openings required around this equipment, since these details can vary between system types.

#Gauges indicating the temperature within the body cabinet must be clearly visible above the door of the unit in order that this can be readily monitored.

#The acceptable average temperature within a normal body cabinet or refrigerated room is between 2.0˚C and 6˚C. In instances where a body has to be kept for an extended period of time a cabinet temperature of at least -20˚C is required.

#In facilities where large quantities of bodies are kept, cold rooms for the storage of multiple bodies on trays are recommended.

#The materials used for the construction of the units are to be of stainless steel to facilitate cleaning and long-term maintenance of the equipment. Grade 316 stainless steel (18/10) is preferable over Grade 304 (18/8), as it offers better corrosion resistance'''.'''

#For welded stainless steel construction, Grade 316L or similar is required.

#If a facility is required to collect and retain forensic samples, refrigeration equipment should be provided for the preservation of these samples. Preferably this equipment should be placed in an area where <s>they</s> it can readily be secured from unauthorised access and tampering.

 

#SECURITY ARRANGEMENTS

#Due to the medical and legal nature of the contents of a mortuary, it is essential that a mortuary has good access control and security systems.

#Theft from mortuaries should be forestalled by, inter alia, constantly monitoring all entrances and preventing free access to mortuary areas. This is especially important for the body- storage areas. Access card or tag systems are open to misuse and are not an appropriate access- control measure. Combinations of tag and biometric access- control systems are recommended.

#Door closers with a “hold-open” mechanism should be installed on the mortuary room doors. This enables doors to close automatically with normal traffic, but can also be held open when moving equipment or trolleys through. “Crash”- type doors should be avoided as these are not easily cleanable and are subject to damage and abuse.

#It is recommended that a timed alarm be fitted to doors to ensure that they are closed shortly after any entrance or exit. This is to <s>mitigate</s> militate against the tendency of keeping doors open with some form of door stopper.

#Body cabinets are to be fitted with locks to prevent the unauthorised opening of these units to forestall the theft of any personal items of the deceased.

#In instances where historical problems relating to unauthorized entry into mortuaries is evident, it is recommended that closed-circuit TV systems be installed to help in monitoring and securing the facility.

PART C – Operation

#OBJECTIVES

The project planning, design, construction and commissioning should aim to provide:

#a safe, secure and functional environment for visitors and staff;

#low capital and ongoing operating costs (service, staffing and maintenance);

#an environmentally appropriate design solution; and

#a fully accessible, inclusive environment.

 

#HEALTH AND SAFETY

In light of the above it is essential that every effort be made to ensure that personnel working in the mortuary are provided with all required personal protective equipment (PPE), as this is essentially an area where pathogens could be present and present a health risk to staff. The following items should be available to staff as a minimum:

#Rubber aprons (or similar impervious material)

#Latex gloves (or similar impervious material)

#Mesh gloves in facilities where post mortems are performed

#Disposable gowns

#Safety glasses or full-face visors.

#Waterproof footwear

#Face masks

#Respirators with the appropriate filters must be available for use in high-risk situations.

#Storage space for PPE

No one should be permitted to enter the body storage and preparation areas without donning appropriate gowns and footwear.

#MAINTENANCE

When designing the facility, every effort must be made to limit the amount of maintenance that would be necessary to keep it in good condition. Seamless surfaces for walls and floors are critical, as this will reduce ongoing maintenance costs. The following minimum requirements should be complied with:

#Seamless floor coverings required

#Radiuses corners ??? required between floors and walls.

#No sharp corners on any work surfaces that could injure people working in the area.

#Ceilings to be readily cleanable.

#Work surfaces are to be impervious to liquids and resistant to staining and corrosion.

#Refer to the room- requirement sheets herein and the IUSS Materials and Finishes guidance documents for further information on the general requirements for materials and finishes.

#All equipment requiring calibration, such as fridges and scales, are to be attended to on an annual basis or when it is suspected that they are defective in respect of their expected/intended performance

PART D – User Room Requirements

Room-requirement sheets

Table 3: Accommodation schedule
{| class="wikitable"
|'''Room Name'''
|'''Service Description'''
 
|'''Area'''

'''(m²)'''
|'''Min. Ceiling Height'''

'''(m)'''
|'''Occupancy'''

'''(Persons)'''
|'''Nominal Utilisation per day'''

'''(hours)'''
|-
|Ablution areas
|Ablution areas – male and female

One WHB per WC or urinal
|3 (per cubicle)
|2.8
|1
|4
|-
|Shower facilities
|Shower facilities – male and female
|3 (per cubicle)
|2.8
|1
|2
|-
|Changing room
|Staff changing room - lockers to be provided
|8
|2.8
|2
|2
|-
|Storage space
|Equipment and PPE storage space
 
|8
|2.8
|1
|1
|-
|Offices
|Office space – interview, body receiving, pathologist
|9
|2.8
|2
|8
|-
|Body/bier room
|Area where a body can be laid out for viewing and identification
|9
|2.8
|1
|8
|-
|Viewing room
|Viewing room – external to body- layout area
|9
|2.8
|4
|1
|-
|Autopsy room
|Autopsy facility – Autopsy table with water supply and discharge and extraction ventilation. WHBs and stainless steel working surfaces
|27
|2.8
|3
|3
|}

'''Table 4: Room services sheet'''
 
{| class="wikitable"
|'''Room Name'''
|'''Temp'''

'''(°C)'''
|'''Ventilation'''

'''(AC/h)'''
|'''Ventilation'''

'''Type'''
|'''Pressure Relative to'''

'''Ambient'''
|'''Wet Services'''
|'''SSO'''

'''400V'''
|'''SSO'''

'''230V'''
|'''Task Illuminance'''

'''(lux)'''
|'''Data Points'''
|'''Colour Rendering'''

'''(Ra)'''
|-
|Reception area
|22-25°C
|2
|Forced supply
|=
|
|0
|0
|100 at floor level
|0
|80
|-
|Visitors ablution areas
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|WC,

WHB
|0
|0
|150 at floor level
|0
|80
|-
|Public waiting area
|22-25°C
|2
|Forced supply
|<nowiki>+ </nowiki>
|
|0
|0
|100 at floor level
|0
|80
|-
|Offices
|22-25°C
|2
|Forced supply/ recirc.
|=
|
|0
|2
|300 at desk level
|1
|80
|-
|Circulation Spaces
|22-25°C
|10
|Forced supply/ recirc.
|=
|
|0
|0
|200 at floor level
|0
|80
|-
|Viewing room
|22-25°C
|2
|Forced supply
|<nowiki>+ </nowiki>
|
|0
|0
|100 at floor level
|0
|80
|-
|Layout room
|20-21°C
|2
|Forced extraction
|<nowiki>- </nowiki>
|WHB
|0
|0
|300 at table level
|1
|80
|-
|Storage space
|22-25°C
|4
|Forced supply
|=
|
|0
|1
|200 at floor level
|0
|80
|-
|Mortuary
|20-21°C
|12
|Forced extraction
|<nowiki>- </nowiki>
|WHB,

FD
|0
|1
|200 at floor level
|0
|80
|-
|Mortuary plant area
|n/a
|n/a
|Natural ventilation
|=
|
|1
|1
|150 at floor level
|0
|80
|-
|Autopsy table
|20-21°C
|20
|Forced extraction
|<nowiki>- </nowiki>
|CW Faucet
|0
|1
|5200 at table level
|0
|90
|-
|Autopsy room
|20-21°C
|20
|Forced extraction
|<nowiki>- </nowiki>
|WHBs,

FD
|0
|2
|500 at floor level
|1
|90
|-
|Changing room
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|WHB
|0
|1
|150 at floor level
|0
|80
|-
|Staff ablution areas
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|WHB,

WC
|0
|0
|150 at floor level
|0
|80
|-
|Shower facilities
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|CW + HW

Faucet
|0
|0
|150 at floor level
|0
|80
|}

'''Table 5: Room finishes'''
 
{| class="wikitable"
|'''Room Name'''
|'''Floor'''

'''Material'''
|'''Wall / Floor Interface'''
|'''Walls'''

'''Finish'''
|'''Ceiling'''

'''Finish'''
|'''Glazing'''

'''Type'''
|'''WHB'''
|'''Doors'''

'''Type'''
|-
|Ablution areas (all)
|Jointless vinyl sheet
|Skirting coved and finished as per floor
|Ceramic wall tiles with epoxy grout
|Washable acrylic paint
|Obscure laminate safety glass
|1 per WC or urinal
|Solid wood with galvanised steel or stainless steel sheet trolley plates
|-
|Public waiting area
|Jointless vinyl sheet
|Coved vinyl skirting
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Lockable glazed entrance door
|-
|Changing room
|Jointless vinyl sheet
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Obscure laminate safety glass
|0
|Solid wood with galvanised steel or stainless steel sheet trolley plates
|-
|Storage space
|Jointless vinyl sheet
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood with galvanised steel or stainless steel sheet cladding
|-
|Offices
|Jointless vinyl sheet
|Coved vinyl skirting
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood
|-
|Body Room
|Self- levelling epoxy
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood
|-
|Viewing Room
|Self- levelling epoxy
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood
|-
|Autopsy Room
|Self- levelling epoxy
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Obscure laminate safety glass
|Min 1 per autopsy table
|Solid wood with galvanised steel or stainless steel sheet cladding
|-
|Circulation Spaces
|Jointless vinyl sheet
|Coved vinyl skirting
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|
|}
'''PART E – Examples and case studies'''

Figure 4 demonstrates the relationships between the zones within the mortuary. In this example it is evident how visitors are managed and kept out of the working portions of the mortuary through segregation in the internal layout. The process flow of the bodies into, through and out of the mortuary has been well considered in that the flow is linear with bodies entering the mortuary <s>on</s>at one end of the facility and exiting at the other. Unfortunately, the restrictions presented by the location of the mortuary, as can be studied in Figure 3, has forced the design into a number of compromises relating to the external flow and access to the mortuary. Staff access is quite severely compromised in being through the mortuary lobby. This mortuary lobby, in the absence of a dedicated preparation room, has the potential of being used as one. This arrangement may impact negatively on the dignity of some staff, the dignity of the deceased, and mortuary security.

Visitors’ access to the mortuary and their adjacent toilets is near the hearse bay and turning areas. There is no natural screening of this entrance from the activities in the hearse bay and it is not inconceivable that visitors may inadvertently wander into the wrong area and be exposed to operational activities not appropriate for the bereaved.

The door sizes of the body storage rooms seem too small for the easy passage of a body trolley when compared to the double doors made available for the passage of the body from there through the remainder of the facility. Door size selection should not be limited by the fact that these are cold room doors. Where doors are too small for free passage of trolleys and porters, <s>their</s> the doors’ service life would be severely shortened and any savings made on the door selection would be lost to maintenance or retrofitting an improved solution.

The access to the technical area for maintenance of the refrigeration equipment in this example meets the recommendations. Here technicians do not need to enter the mortuary to perform the majority of their work and these areas are quite well separated from the admin and visitors’ areas.

 

#EXAMPLE 2: LARGE MORTUARY WITH AUTOPSY FACILITIES

Figure 5 shows the layout of a standardised mortuary design. This is a large facility with autopsy capacity. Figure 6 has been presented in order to promote an understanding of the interrelationship between the various functional parts of the mortuary.

Considering the entrances shown in Figure 5, it is clear that the designer has <s>taken some</s>made an effort to screen the <s>visitor’s</s> visitors’ entrance from the hearses’ entrance. The staff entrance is also well positioned. The staff ablution<s>s</s> facilities and showers are located between the clinical areas and the admin areas. This arrangement encourages good segregation and gowning practice when moving between the mortuary activities and external movement.

The staff and visitors’ access positions are located well away from the working clinical areas of the mortuary and are also relatively remote from each other. This aids in improving security as it discourages the staff and visitors from using the wrong entrances and thereby assists in identifying persons who are present in areas where they do not belong.

This design doesn’t have a dedicated body prep area and it is assumed that the weighing and measuring area is therefore used for this purpose.

The large sliding doors of the cold room in this example can be compared to the cold-room doors in Figure 3 as an indication of what the door size should be like to enable easy passage.

The layout in this example does not provide for a dedicated exit yard and bodies and hearses entering and leaving the facility do so through the same entrance. This arrangement increases the potential for mistakes in body handling.

The common use of the bier room as access to the ID room seems to be a compromise resulting from the limited space provided for these rooms.

'''EXAMPLE 3: LARGE MORTUARY WITH AUTOPSY FACILITIES'''

The example shown in Figure 7<s>Figure 7</s> is a standard facility layout, very similar to that of Figure 5<s>Figure 5</s>, with the most notable changes being the inclusion of a dedicated vehicle- exit yard and the omission of the technical service area. The addition of the exit detail resolves the criticism of the arrangement in Example 2, while the omission of the technical service area for the refrigeration equipment could present an access problem for maintenance technicians, as discussed earlier in this document.

The example in Figure 7<s>Figure 7</s> has also resolved the compromises <s>to</s> in the arrangement of the bier rooms and ID/viewing rooms’ available space, discussed in the previous example.

'''DEFINITIONS'''

In the context of this document the following definitions pertain:
{| class="wikitable"
|'''Autopsy room:''' Synonymous with post–mortem examination area or suite.
|-
|'''Containment facility:''' The part within the demarcated zone in which the most malodorous activities occur. This facility includes the decomposing bodies’ post-mortem examination room, airlock ante room, and a decontamination unit each for men and women. The containment facility is sealed off from the rest of the demarcated area.
|-
|'''Demarcated area:''' The demarcated area, including the post-mortem examination rooms and all supporting functional spaces is the area where most sensitive, costly and specialised processes occur.
|-
|'''Dignity of deceased:''' The principle that bodies are treated with the respect and dignity befitting any person prior to death.
|-
|'''Dissection room or suite:''' Synonymous with post-mortem examination area or suite.
|-
|'''Mortuary:''' A mortuary is a facility for temporary storage of the deceased pending identification, medico-legal investigation and despatch.
|-
|'''Natural death:''' A death <s>by</s>from natural causes which <s>is</s> are determined to have been the cause of illness <s>of</s>or an internal malfunction of the body <s>which was</s> not caused by external forces.
|-
|'''Post-mortem examination area or suite''': A room and its attached service rooms designed for the performing of post-mortem examinations.
|-
|'''Post-mortem examination:''' Examination after death, which may include performance of an autopsy.
|-
|'''Unnatural death:''' A death which is not classified as being a '''''Natural Death'''''
|-
|'''Work bench (or bench):''' Unless otherwise specified, this is a surface ergonomically dimensioned for use from the standing position. This is normally 900mm.
|-
|'''Work-station:''' Unless otherwise specified, this is a surface ergonomically dimensioned for use from the seated position. This is normally 750mm. ??
|}

Page Break

'''BIBLIOGRAPHY'''

To be sorted out and made consistent - as advised to Mr Van Reenen
{| class="wikitable"
|REQUIREMENTS FOR THE FACILITIES AND OPERATION OF MORTUARIES (Second Edition 2009), NPAAC Tier 4 Standard. Australian Government Department of Health and Ageing.
|-
|MANAGING HEALTH AND SAFETY RISKS IN NEW ZEALAND MORTUARIES.(November 2000) Dr Chris Wells and Dr Jeff Brownless
|-
|Mortuary design and hazards. J. clin. Path. (1961), 14, 103
|-
|Health Authority Abu Dhabi. Part B- Version 3.1, June 2011
|-
|Design and layout of Mortuary Complex for a Medical College and Peripheral Hospitals. (2011) BasantLalSirohiwal, Paliwal PK, Luv Sharma and Hitesh Charlwa
|-
|Planning and design of modern mortuary complex in tertiary care. IIJFMT 4(1) 2006. Dr Sanju Singh, Dr U.S. Sinha, Dr A.K. Kapoor, Dr S.K. Verma, Dr Dalbir Singh, Dr Susheel Sharma
|-
|Australian Health Facility guidelines. Revision v.4.0 16-Dec-10
|-
|Mortuary Facilities – Design and improvement guide. CSIR March 2002
|-
|Project development brief for the new academic M6 pathology forensic laboratory. Western Cape Department of Health, August 2009
|-
|National Code of Guidelines for Forensic Pathology Practice in South Africa. Edited by NFPSC Academic Sub-committee 20 August 2007
|-
|IUSS Building Engineering Services guidance document
|}
{{Expand}}
[[Category:Procurement and Operation]]

Maintenance

2022-07-25T09:31:24Z

Tmojanaga: Changed heading

== Contents ==
OVERVIEW 5<s>6</s>

'''''Abbreviations''''' 9<s>8</s>

PART A – POLICY AND SERVICE CONTEXT 11<s>9</s>

Legislation, policies and international guidance 11<s>9</s>

1. LEGISLATIVE CONTEXT 11<s>9</s>

2. Further reference material and precedent<s>:</s> 11<s>9</s>

3. INFECTION PREVENTION AND CONTROL LEGISLATION 12<s>10</s>

4. BUILDING LEGISLATION 12<s>10</s>

5. SOUTH AFRICAN BUILDING PRACTICE POLICY AND GUIDELINES 12<s>10</s>

6. INTERNATIONAL DESIGN GUIDANCE 12<s>10</s>

Service Context 13<s>11</s>

PART B – PLANNING AND DESIGN 15<s>12</s>

1. INTRODUCTION 15<s>12</s>

2. LOCATION OF THE MORTUARY AND ACCESS ROUTES 16<s>13</s>

3. FACILITY CAPACITY 16<s>13</s>

4. SELECTING BODY STORAGE SYSTEMS 18<s>14</s>

5. FACILITY LAYOUT 18<s>15</s>

6. MORTUARY EQUIPMENT REQUIREMENTS 21<s>17</s>

7. MOVEMENT WITHIN A MORTUARY 22<s>18</s>

8. SERVICES REQUIRED 24<s>19</s>

9. BIOLOGICAL SAFETY 24<s>19</s>

10. FINISHES TO FLOORS AND WALLS 25<s>20</s>

11. AUTOPSY EQUIPMENT/FIXTURES 26<s>20</s>

12. VENTILATION 27<s>21</s>

13. AIR CONDITIONING 27<s>22</s>

14. REFRIGERATION EQUIPMENT DESIGN AND INSTALLATION 28<s>22</s>

15. SECURITY ARRANGEMENTS 28<s>22</s>

PART C – OPERATION 30<s>24</s>

1. OBJECTIVES 30<s>24</s>

2. HEALTH AND SAFETY 30<s>24</s>

3. MAINTENANCE 30<s>24</s>

PART D –USER ROOM REQUIREMENTS 32<s>32</s>

Room Requirement Sheets 32<s>32</s>

PART E – EXAMPLES AND CASE STUDIES 36<s>35</s>

Layout Examples 36<s>35</s>

1. EXAMPLE 1: SMALL MORTUARY ATTACHED TO HOSPITAL 38<s>36</s>

2. EXAMPLE 2: LARGE MORTUARY WITH AUTOPSY FACILITIES 39<s>37</s>

3. EXAMPLE 3: LARGE MORTUARY WITH AUTOPSY FACILITIES 43<s>40</s>

BIBLIOGRAPHY 46<s>42</s>

'''Table of Figures'''

Figure 1 Adjacency Diagram 1<s>16</s>

Figure 2: Access and Movement in a mortuary 1<s>18</s>

Figure 3 Example 1: Layout 1<s>35</s>

Figure 4 Example 1: Zoning & Access 1<s>36</s>

Figure 5 Example 2: Layout 1<s>38</s>

Figure 6 Example 2: Zoning and Access 1<s>39</s>

Figure 7 Example 3: Layout 1<s>40</s>

'''Table of Tables'''

Table 1 : IUSS Reference documents 8<s>7</s>

Table 2 Service Requirements 13<s>11</s>

Table 3 Accommodation Schedule 32<s>25</s>

TABLE 4 ROOM SERVICES SHEET 33<s>26</s>

TABLE 5 ROOM FINISHES 34<s>27</s>

''Version Control''
{| class="wikitable"
|''Template''
|''January 2013''
|''Tobias van Reenen''
|-
|''Discussion Draft 1''
|''February 2013''
|''Steve Fourie''
|-
|''Discussion Draft 5''
|''March 2013''
|''Steve Fourie''
|-
|''Discussion Draft 6''
|''May 2013''
|''Steve Fourie''
|-
|''Development Draft 1''
|''August 2013''
|''Tobias van Reenen''
|-
|''Development Draft 3.1''
|''February 2014''
|''Tobias van Reenen''
|-
|''Development Draft 3.1''
|''February 2014''
|''Prof J Vellema''
|}

Page Break

OVERVIEW

This document outlines the policy and service context and attempts to illustrate the desired planning principles and design considerations for mortuary services.

*''Part A'' outlines the South African legislation, policies and international guidance reference documents and the service context with respect to mortuary services;
*''Part B'' Planning and design;
*''Part C'' operation;
*''Part D'' user room requirements; and
*''Part E'' provides case studies.

Parts D and E are intended to demonstrate how the principles prescribed in Part A, B, and C can be applied in worked examples. Part D, if used directly, are deemed<s>-</s> to<s>-</s> satisfy the principles developed in Part B, but are not the only acceptable solutions.

Case studies (Part E) provide illustrative worked solutions and should not be adopted without appropriate contextual adaptation.

While this document outlines design requirements and acceptance criteria which have an impact on clinical services, these requirements are prescribed within the framework of the entire IUSS set of guidance documents and cannot be viewed in isolation. The following documents should be complied with, together with this document:

*IUSS: Regulations
*IUSS: Project Planning and Briefing
*IUSS: Environment and Sustainability
*IUSS: Hospital Design Principles
*IUSS: Infection Prevention and Control

Page Break

The following table identifies additional IUSS guideline documents which are recommended for reading in conjunction with this guideline.

'''Table 1 : IUSS Reference documents'''
{| class="wikitable"
|

'''CLINICAL'''

'''SERVICES'''
 
|Essential
|Recommended
|'''SUPPORT'''

'''SERVICES'''
|Essential
|Recommended
|'''HEALTHCARE ENVIRONMENT/ CROSSCUTTING ISSUES'''
|Essential
|Recommended
|'''PROCUREMENT'''

'''& OPERATION'''
|Essential
|Recommended
|-
|Adult Inpatient Services
|
|X
 
|Administration and Related Services
|
|
|Generic Room Requirements
|
|
|Integrated Infrastructure Planning
|
|
|-
|Clinical and Specialised Diagnostic Laboratory Guidelines
|
|X
|General Hospital Support Services
|
|X
|Hospital Design Principles
|
|
|Briefing Manual
|
|X
|-
|Mental Health
|
|
|Catering Services for Hospitals
|
|
|Building Engineering Services
|X
|
|Space Guidelines
|
|
|-
|Adult Critical Care
|
|
|Laundry and Linen Department
|
|X
|Environment and Sustainability
|
|
|Cost Guidelines
|
|
|-
|Emergency Centres
|
|
|Hospital Mortuary Services
|
|
|Materials and Finishes
|X
|
|Procurement
|
|
|-
|Maternity Care Facilities
|
|
|Nursing Education Institutions
|
|
|Future Healthcare Environments
|
|X
|Commissioning Health Facilities
|X
|
|-
|Adult Oncology Facilities
|
|
|Health Facility Residential
|
|
|Healthcare Technology
|
|
|Maintenance
|X
|
|-
|Outpatient Facilities
|
|X
|Central Sterile Service Department
|
|
|Inclusive Environments
|
|
|Decommissioning
|X
|
|-
|Paediatrics and Neonatal Facilities
|
|
|Training and Resource Centre
|
|X
|Infection Preventive Control
|X
|
|Capacity Development
|
|
|-
|Pharmacy
|
|
|Waste Disposal
|
|X
|Health Informatics
|
|
|
|
|
|-
|Primary Health Care Clinics and CHCs
|
|
|
|
|
|Regulations
|
|
|
|
|
|-
|Diagnostic Radiology
|
|
|
|
|
|
|
|
|
|
|
|-
|Adult Physical Rehabilitation
|
|
|
|
|
|
|
|
|
|
|
|-
|Sub-acute services
|
|
|
|
|
|
|
|
|
|
|
|-
|Facilities for Surgical Procedures
|
|
|
|
|
|
|
|
|
|
|
|-
|TB Services
|
|
|
|
|
|
|
|
|
|
|
|}

'''''Abbreviations'''''
{| class="wikitable"
|ACH
|Air changes per hour
|-
|ASHRAE
|American Society of Heating, Refrigerating, and Air-Conditioning Engineers
|-
|BMS
|Building Management System
|-
|BSL
|Biological safety level
|-
|CDC
|Centers for Disease Control (USA)
|-
|CSIR
|Council for Scientific and Industrial Research
|-
|FD
|Floor drain
|-
|FPS
|Forensic Pathology Service
|-
|HVAC
|Heating Ventilation Air Conditioning
|-
|HBA
|Hazardous biological agents
|-
|HCS
|Hazardous chemical substances
|-
|HEPA
|High efficiency particulate air filters
|-
|IPC
|Infection prevention and control
|-
|ISO
|International Standards Organisation
|-
|MDR TB
|Multi-drug resistant TB
|-
|NDoH
|National Department of Health
|-
|NBR
|National Building Regulations
|-
|<s>NDoH</s>
|<s>National Department of Health</s>
|-
|NHS
|National Health Service (UK health service)
|-
|NIOSH
|National Institute of Occupational Safety and Health (US agency)
|-
|O&M
|Operating and Maintenance (manual)
|-
|OHS
|Occupational health and safety
|-
|OQ
|Operational qualification
|-
|PGWCDoH
|Provincial Government Western Cape Department of Health
|-
|PPE
|Personal protective equipment
|-
|PQ
|Performance qualification
|-
|RDS
|Room data sheets
|-
|RH
|Relative humidity
|-
|SABS
|South African Bureau of Standards
|-
|SAO
|Senior Administrative Officer
|-
|SAPS
|South African Police Service
|-
|SI
|<s>Le Systeme International d' Unites</s> Le Système International d’Unités
|-
|SOP
|Standard Operating Procedures
|-
|SS
|Stainless steel
|-
|TB
|Tuberculosis
|-
|WC
|Toilet
|-
|WHB
|Wash-hand basin
|-
|WHO
|World Health Organisation
|-
|XDR TB
|Extreme (or extensively) <s>-</s>drug- resistant TB
|-
|
|
|-
|
|
|-
|
|
|}
PART A – Policy and service context

Legislation, policies and international guidance
 

#LEGISLATIVE CONTEXT

The following documents, as amended (though not an exhaustive list) pertain and contain an additional resource of information which would supplement and provide the basis of a design brief. A finer sense of standard operating procedures and legislative context is likely to inform and enhance the design process, so the professional teams are encouraged to use these as an additional resource:
 

*Inquest Act<s>,</s> 58, 1959
*National Health Act<s>,</s> 61, 2003
*Government Notice R363, 2013 [Regulations relating to the management of human remains]
*Government Notice R178, 2012 [Regulations relating to the registration of microbiological laboratories and the acquisition, importation, handling, maintenance and supply of human pathogens]

*Health Professions Amendment Act, 29, 2007
*Criminal Procedures Act<s>,</s> 51, 1977
*Births and Deaths Registration Act<s>,</s> 51, 1992
*National Environmental Management: Waste Act<s>,</s> 59, 2008
*National Archives of South Africa Act<s>,</s> 42, 1996

*Regulations regarding the Rendering of Forensic Pathology Service, ''Government Gazette'' No 30075. No R636, 20 July 2007
*Space Planning Norms and Standards for Office Accommodation used by Organs of State, ''Government Gazette'' No 27985. No 1665, 2 Sept 2005
*Western Cape Health Care Waste Management Draft Bill
*Municipal by<s>-</s>laws, as applicable
*National Code of Guidelines for Forensic Pathology Practice in South Africa, 20 Aug 2007

*Standard Operating Procedures, Forensic Pathology Service, PGWCDoH, 2006
*Biosafety in Microbiological and Biomedical Laboratories, U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention and National Institutes of Health, Fifth Edition, <s>2007</s> US Government Printing Office, Washington: 2007

 

#Further reference material and precedent<s>:</s>

 

*Standard specification for air-conditioning and ventilation systems, Western Cape Department of Public Works, 1998
*Fire security: a guide for architects, Western Cape Department of Public Works, 1998
*Standard electrical specification, South African Department of Public Works, 2005
*Facilities for mortuary and post-mortem room services, NHS Estates, 2001, ISBN 0-11-322000-00
*Part B – Health facility briefing and planning, Australasian Health Facilities Guidelines, 2007

*CKS 336: 2013 Mortuary Trolleys - SABS

#INFECTION PREVENTION AND CONTROL LEGISLATION

The National Infection Prevention and Control Policy and Strategy document makes specific reference to certain Acts and their relevant regulations, which bear relevance to the development and implementation of these health facility guidelines. These are:

*The South African Constitution, 1996 [Sections 2, 24, 27, 36 and 39], as amended
*The Occupational Health and Safety Act of 1993, Act No 85 of 1993 [Section 8(1)]

*Government notice R1390 of 27 December 2001 [Hazardous Biological Agents Regulation] as promulgated under Section 43 of the Occupational Health and Safety Act of 1993
*Government notice R908 of 27 June 2003 [Hazard Analysis Critical Control Point Regulation] as promulgated under Section 15(1) of the Foodstuffs, Cosmetic and Disinfectants Act of 1972
*The Environmental Conservation Act of 1989, Act No 73 of 1989
*The Foodstuffs, Cosmetic and Disinfectants Act of 1972, Act No 45 of 1972

 

#BUILDING LEGISLATION

The following legislation and regulations impact and provide guidance on the provision and design of health care facilities as above:

*The National Environmental Management Act 107 of 1998, as amended
*Building regulations and Building Standards Act 103 of 1977, as amended
*National Building Regulations; SANS 10400:2010, Code of Practice for the Application of the National Building Regulations

*Promotion of Equality and Prevention of Unfair Discrimination Act No 4 of 2000
*General Procedures and Loadings adopted in the Design of Buildings, SABS 0160, 1993
*Structural Use of Concrete Design, SABS 0100-1, 1992
*Structural Use of Concrete – Materials and Execution of Work, SABS 0100-2, 1992
*Specification for Civil Engineering Construction SABS 1200

 

#SOUTH AFRICAN BUILDING PRACTICE POLICY AND GUIDELINES

*R158 of 1980 regulations pertaining to Private Hospitals and Unattached Operating Theatres – R198
*Good Pharmacy Practice, Board Notice 129 of 2004, as amended [see Chapter 1].

#INTERNATIONAL DESIGN GUIDANCE

*ASHRAE Standard 52.2, “Method of Testing General Ventilation Air-Cleaning Devices for Removal Efficiency by Particle Size”, 1992, 1999b
*ASHRAE Standard 62, “Ventilation for Acceptable Indoor Air Quality”, 1989
*ASHRAE. “HVAC Design Manual for Hospitals and Clinics, 2003”, 1989
*CIBSE Applications Manual AM10:1997 “Natural Ventilation in Non-Domestic Buildings”, 1998
*CIBSE Applications Manual AM13:2000 “Mixed Mode Ventilation,” 2000

*ASHRAE Standard 170, “Ventilation of Health Care Facilities”, 2008
*QASA. “Know Your Rights” [Accessibility & the Built Environment]
*Department of Health and Human Services. “Environmental Control for Tuberculosis: Basic Upper-Room Ultraviolet Germicidal Irradiation - Guidelines for Healthcare Settings”, 2009
*WHO. “WHO Policy on TB Infection Control in Health-Care Facilities, Congregate Settings and Households”, 2009

Guidance has also been provided by AIA (USA), NHS (UK), and Australian Health Facility Guidelines on Healthcare Building Design. Additional references can be sourced from www.tb-ipcp.co.za

Service Context

The following table gives an indication of the service requirements for mortuaries within different types of public hospitals.

Table 2: Service Requirements
{| class="wikitable"
|'''Service'''
|'''District'''
|'''Regional'''
|'''Tertiary'''
|'''Central'''
|'''Specialised'''
|-
|Small (beds)
|50-150
|Min 300
|Min 400
|
|
|-
|Medium (beds)
|150-300
|
|
|
|
|-
|Large (beds)
|300-600
|Max 800
|Max 800
|Max 1200
|Max 600
|-
|Training
|Where practical
|Where practical
|Optional
|Yes. Attached to medical school
|
|-
|Conduct research
|
|
|
|Yes
|
|-
|'''Mortuary'''
|
|
|
|
|
|-
|Short-term stay (2˚C)
|Yes
|Yes
|Yes
|Yes
|
|-
|Long-term stay (-15˚C)
|Yes
|Yes
|Yes
|Yes
|
|-
|Autopsies (20°C -21°C)
|Yes
|Yes
|Yes
|Yes
|Yes
|}

For the determination of capacity requirements of mortuaries refer to the recommendations further on in this document.

This guidance document relates to mortuaries located within and serving hospitals, with respect to persons that die due to natural causes in that hospital. This document excludes mortuaries <s>exclusively</s> dealing exclusively with cases that require medico-legal investigation of deaths from unnatural causes.

Post mortems conducted in hospital mortuaries should be limited to conducting investigations and procedures where no medico-legal investigation is required and death from natural causes is suspected.

Hospital deaths from natural causes and those suspected to be of unnatural cases should not be managed in the same facility unless the hospital mortuary is equipped to comply with the specific legal requirements as <s>it</s> they relate<s>s</s> to the chain of evidence, etc. The requirements for forensic- pathology service mortuaries are not exhaustively detailed in this document.

It is also noted that some hospitals may opt to contract out the removal and storage of decedents to private undertakers and these hospitals may <s>only</s> require only the minimum in terms of refrigerated body storage.

PART B – Planning and Design

#INTRODUCTION

#All state- run mortuary facilities fall within the domain of the Department of Health, both National and Provincial;<s>,</s> and in an effort to provide engineers and architects who are required to either design new facilities or upgrade existing facilities, this document provides the minimum standards necessary to comply with existing legislation.

#This document will provide designers of this type of facility with guidelines as to what is required in terms of the following:

*Type of service and package of care being provided
*Mortality rate
*Access and egress
*Discreet management of human remains

*Size and dimensions of the actual facility
*Positioning of mortuaries within hospitals
*Finishes of surfaces in these facilities
*Water- supply requirements
*Drainage requirements

*Electrical supply and lighting requirements
*Installation requirements for equipment and services
*Body-storage requirements
*Body-handling facilities
*Body-holding areas

*Body-viewing area
*Autopsy equipment (tables)
*Air conditioning and ventilation requirements (for infection and indoor air quality control)
*Security of the facility

#In addition to the items listed above, it is also necessary to consider the needs of visitors to these facilities, particularly those wishing to, or who are required to, identify bodies. In line with this it is also necessary to take the handling of bodies into consideration as it pertains to issues of patient dignity.

#Forensic pathology mortuaries are not <s>considered</s> exhaustively described in this document, although the majority of mortuaries do have basic facilities for general autopsies that are not necessarily medico-legal in nature. A forensic pathology mortuary has laboratory facilities attached that are outside the scope of regular mortuaries found in hospitals and at police stations. It should be noted that there are a number of principles that hold true for both hospital and forensic pathology mortuaries.

#Compliance with the requirements of the Occupational Health and Safety Act (Act 85 of 1993 as amended) are to be complied with at all times during the design of a mortuary.

 

#LOCATION OF THE MORTUARY AND ACCESS ROUTES

#The position of the mortuary in a hospital should be such that the mortuary is easily accessible to mortuary staff and related service providers without presenting either aesthetic, emotional or ethical problems for unrelated hospital staff, patients or visitors. Visitors to the mortuary, however, should be provided with clear and direct access to the mortuary upon arrival at the hospital, without having to travel unnecessarily through hospital departments.

#Where bodies are moved into or out of the mortuary, they should not be moved through general public-access areas. Appropriate routes would include technical service or goods corridors and through the hospital’s support services yard.

#Special considerations should be given to plans for contingency access to the mortuary in the event of case- load surges, which may <s>be</s> result from disasters.

#Bodies should not be held for any period in any locations between the body- holding rooms within clinical areas and the mortuary.

#Where a mortuary unit is used jointly between the hospital and the local authority it is beneficial for the mortuary to be in a building separate from the main hospital building.

#The delivery of bodies to the mortuary and their subsequent removal from the facility is to be such that it is carried out in a manner that is not visible to the general public, preferably in a covered and enclosed area.

#While siting and access are important aspects when locating a mortuary, it is also important to provide the mortuary with pleasant surroundings in order to promote the dignity of those working in or visiting the mortuary.

 

#FACILITY CAPACITY

#The layout and size of a mortuary is largely determined by the number of bodies stored and whether body storage needs to be in cabinets or in refrigerated rooms.

#In order to determine the storage capacity of a hospital mortuary it is recommended that historical data, where available, should be used. In the South African context it is suggested that a storage capacity of between 5 and 10 bodies per 100 beds should be used. This varies with the rural or urban location of the facility. This capacity should not take into account the need to store bodies from deaths which are not hospital related, typically motor-vehicle accident deaths and deaths from criminal activity. Requirements for contingency storage capacity related to disaster management should be considered.

#The body storage capacity required can be estimated on the basis of the number of deaths per year in the hospital, the length of time of holding and the required body store occupancy rate. The number of body trays can be calculated from Equation 1<s>Equation 1</s> below.

-Equation 1

Where:

BT = Number of body trays

D = Number of deaths per year requiring body trays

S = Average length of stay (in days)

R = Required body tray occupancy rate

[Text Box]

#The estimated storage capacity for bodies in a mortuary could be confounded by a number of local factors, such as:

*Mortality rate from natural causes.
*Mortality rate from infectious disease. (Highly contagious disease deaths require special storage facilities.)

#Where the hospital is expected to place the body in cold storage until collection by forensic pathology services the following additional factors should be considered:

*Mortality rate from foul play.
*Mortality rate from traffic incidents.

 

#SELECTING BODY-STORAGE SYSTEMS

#Body-storage systems are principally divided into refrigerated rooms or body cabinets. Differences within these system types occur where specific temperatures or sizes are required based on risk, need and capacity requirements.

#Where a system of functionally separate body cabinets is selected, this system would have an inherent redundancy against failure, as the failure of a single unit would not necessarily imply a system failure. In contrast, a refrigerated room would require less maintenance and would have a lower frequency of failure; however a single component failure could be critical if standby condensing units are not installed. For this reason, multiple- cabinet systems are recommended for areas where expected maintenance response times would negatively affect the mortuary’s operations.

#It is possible to have a requirement for a mixture of refrigerated rooms and body cabinets. This could be affected by local cultural requirements such as for families <s>which</s> who object to bodies sharing storage space, the case load of the facility or the case profile.

#Where there is a requirement for the long-term storage of bodies, these are to be kept at a lower temperature than would be the case in a refrigerated room. In this instance separate body cabinets are required. Long- term storage of bodies is most often required when an indigent person dies and difficulty is experienced in locating the next of kin, as the person cannot legally be buried until this process has been completed.

#In general, smaller facilities rely on body cabinets for the storage as these facilities do not have the space or the need for the large-scale storage of bodies, <s>and they do not</s>they would not appreciate the functional flexibility offered by these systems. By rule of thumb, any facility that has the requirement to store <s>less</s> fewer than 12 bodies at any given time should use body cabinets. This <s>provides</s> gives the option of providing both short- and long-term storage with the smallest facility and equipment footprint.

#Bodies suspected of having succumbed to a highly contagious and dangerous disease require special treatment. These should be stored in such a manner that they do not present a hazard to personnel working in the mortuary. Typically these bodies should be stored at the same temperature<s>s</s> <s>the same</s> as <s>for</s> long- stay bodies, e.g. -15˚C, and should be placed in hermetically sealed plastic body-bags.

#Provision for the secure cold storage of body parts should <s>also</s> be provided.

 

#FACILITY LAYOUT

#As mentioned, the layout and size of a mortuary is going to be largely determined by case load and whether storage is in cabinets or refrigerated rooms. It is acceptable to have a mixture of refrigerated rooms and body cabinets.

#In a mortuary facility there are a number of separate areas that need to be considered other than the body- storage areas. These include:

#'''Reception area''' for members of the public who are required to visit the mortuary on official business – typically to identify bodies or to pay their last respects to a deceased person.

#'''Ablution areas''' for staff. Where unisex ablutions are provided it is recommended that <s>the</s> no urinal is provided.

#<s>'''Visitor’s'''</s> '''Visitors’ admin space''' close to the reception area, where any admin or official business related to the identifying of a body can be completed.

#'''Staff admin space''' close to the point where a body is delivered to the mortuary, so that pertinent documentation can be completed – both with respect to the delivery of the body, as well as when the body is released from the mortuary again.

#'''Office space''' for pathologists to write up reports <s>for</s> in instances where this could be required. This is dependent on the size of the mortuary as small facilities would not require a separate room(s) for this function.

#'''Waiting''' and circulation areas for visitors to the mortuary.

#'''Viewing room,''' from where a body can be viewed through a curtained glass window between this space and the body- display room.

#'''Body- display''' room, where a body is placed for identification purposes. There is to be access to this area via a lockable door to the viewing room <s>for</s> in instances where it is necessary for non-mortuary personnel to have direct access to a body in the viewing room. There is to be access to this room from the body- storage area to allow bodies to be brought in for display purposes.

#'''Body preparation''' area, where a body that is delivered to the mortuary needs to be attended to prior to it being placed in the viewing room.

#'''Shower facilities''' (staff)

#'''Changing room''' (staff)

#'''Storage space''' for equipment and clothing that is worn in the body-preparation and autopsy spaces.

#'''Body-storage''' facility (cold room or refrigerated cabinets), depending on the length of time that bodies are expected to be kept in the facility.

#'''Autopsy facility,''' where the cause of death can be determined. This facility will differ from mortuary to mortuary, depending on whether forensic or standard medical autopsies to determine the cause of death are conducted.

[GroupDrawing]
 

#Figure 1<s>Figure 1</s> is an example of an adjacency diagram for a typical mortuary. In this instance the proximity also relates to visual and physical access. It is also understood that not all mortuaries would require all of the spaces indicated in this diagram, and that some of the spaces shown as being '''''immediately adjacent''''' could be included as a single area if functionality and privacy considerations permit it.

#There remains abundant scope for variations in the planning of the layouts making up the mortuary. and the hospital architect should consult with all stakeholders to arrive at an ideal solution.

#When developing the facility layout, careful consideration should be given to the routes through the facility of staff, bodies and visitors. These routes should overlap as little as possible and there should never be a common entrance for bodies and staff or visitors.

#The room requirement sheets are presented in ''PART D – User Room Requirements<s>PART D –User Room Requirements</s>''of this document.

#Storage space for body lifts must be provided.

#Suitable sluicing facilities are required to be able to clean equipment and fabrics after completion of any work in the mortuary facility.

 

#MORTUARY EQUIPMENT REQUIREMENTS

#Equipment for storage and transportation of bodies should meet environmental hygiene standards.

#For mortuary trolley design and supply, the SABS published standard '''''CKS336:2013 Mortuary Trolleys''''' is recommended. It should be noted that this is not a normative South African National Standard, and individual requirements may differ.

#'''Body-cabinet''' selection and installation requires the following considerations:

#Three-level body cabinets could be selected which have a single door to give access to all of the body trays, for instances where separation between bodies is required. Alternatively, cabinets that provide a single door for access to all the body trays are acceptable.

#It is critical that bariatric (obese) bodies are catered for in each cabinet. The lowest-level tray should be designed for this purpose.

#Special consideration is to be given to the provision of capacity for storage of juvenile and infant decedents. The handling of these bodies is an especially sensitive and emotive issue, and separate storage in dedicated cabinets is recommended.

#Body lifts must be supplied to facilitate the loading of bodies into and removal of bodies from the cabinets. Body lifts help to preserve dignity when handling bodies, while at the same time making it easier and safer for mortuary personnel to handle bodies.

#A clear space must be provided in front of the body cabinets to allow for the placing of a corpse into the cabinets. It is recommended that there be at least a 3m clearance between the front of the cabinet and any fixed structure. This is to accommodate whatever means of conveyance is used to transport a corpse to ?? and then load it into the cabinet.

#Due to the vast array of cabinets available on the market and the lack of an appropriate national standard, it is not yet possible to prescribe sizes for refrigerated cabinets in this guide.

#The required cabinet size is fundamental when designing a mortuary. Where space is not too limited and there are no indications that there may be cultural concerns relating to the storage of bodies together in a cold room, it is recommended that cold rooms be used. Cold rooms offer space savings when compared to cabinets.

#A temperature gauge must be installed close to the door of the facility to indicate the storage-space temperature. This gauge should have an alarm system connected to it to give a warning should there be an unacceptable rise in temperature in the storage space. Typically, if the temperature should rise more than 2˚C above the set temperature, an alarm should be activated at a point that is manned at all times.

#Body cabinets and refrigerated rooms must be supplied with electrical power from the hospital’s essential services electrical supply.

#A slop hopper is to be provided to allow for the cleaning of the body preparation and autopsy areas, in particular after the completion of any work carried out in these areas.

#To allow for the rinsing of body parts and organs, during an autopsy procedure it is important that suitable basins be provided in close proximity to <s>the</s>a downdraft autopsy table.

#Where there is transition between “clean” and “dirty” areas, provision is to be made to allow for the cleaning of footwear in a “transitional” area. This helps prevent the transport of contaminants from dirty areas.

 

#MOVEMENT WITHIN A MORTUARY

#Movement of members of the public visiting the mortuary is to be restricted such that they do not have access to the body- preparation or autopsy areas. (Figure 2<s>Figure 2</s>)

#The facility must be available within the mortuary where body identification can be conducted in a private and dignified manner. This viewing area should consist of a body- display or layout room with an adjacent viewing room, where the body can be viewed through a curtained shatter-proof glass window.

#The requirement for a viewing and identification area also pertains to hospitals which outsource their mortuary services.

#The viewing room and visitors’ admin rooms should be designed such that counselling can be conducted in a pleasant environment for bereaved persons.

#The design of the viewing facility should allow <s>for</s> adequate space for persons to view a body in a dignified manner.

#Direct access to the body- layout room from the viewing room is to be provided via a lockable door, to allow visitors access to the body.

#Ablution facilities are to be available to members of the public who are required to visit the mortuary complex.

#[GroupDrawing]Where a dedicated room, as described above, cannot be allocated for placing a body for viewing purposes, the persons who are viewing a body should be given a private space for viewing the body through a curtained shatter-proof glass window, as a minimum.

#Adequate facilities to accommodate at least 7 visitors are to be provided.

#Staff access to the mortuary facility is to be separate from the general public. (Figure 2)

#Mortuary staff change rooms should be provided with secure lockers for storage of street garments, lab coats, personal protective equipment and valuables. <s>Street garments and lab garments</s>

#Mortuary staff may have completely separate ablution facilities from those used by the general public requiring access to the mortuary facility.

#In a free- standing mortuary building the delivery to and removal of bodies from the facility may be via the same access point to the building.

#A mortuary that forms an integral part of a hospital will require separate routes for receiving bodies and the subsequent removal thereof.

#In the unusual event that a body arrives from outside <s>of</s> the hospital, the normal route of removal should be used for receipt of the body.

#A clear distinction is to be made between “clean”,” “dirty” / “wet” and “transitional” areas. This is best achieved by creating a physical “RED LINE” on the floor indicating the separation of these areas, with “yellow lines” used to demarcate “transitional” areas. Receptacles for the collections of dirty clothing, etc, must be made available at the transition area from <s>a</s> dirty to clean areas and in change rooms.

#A well-drained facility for washing <s>of</s> vehicles which have been contaminated with decomposed bodies or <s>bodily</s> body fluids should be provided in an enclosed area, near to the mortuary.

 

#SERVICES REQUIRED

#Hygienic floor drains that are resistant to corrosion from blood and chlorine should be provided in all “wet areas” of the mortuary and should be directly connected to the sewer system. These areas include body preparation, autopsy space, etc. These areas require thorough cleaning after every procedure, using large quantities of water and decontaminating and disinfecting chemicals and soaps.<s>.</s>

#Sluicing facilities are to be provided in both the body- preparation and autopsy areas if they are not a common area.

#Open floor channels should be avoided. Where this is not possible, these should be covered by durable, flush- fitted stainless steel grids.

#No sewer connections external to the mortuary services should be made to the line between the wet area drains and the main sewer system in order to prevent backflow to other areas.

#The provision of hot and cold water in the facility is imperative, with all basins, sinks, ablution areas and autopsy tables being provided with both.

#Anti-backflow devices should be fitted to the water- supply lines serving mortuary table faucets to prevent backflow should supply water pressure fail.

#Electricity supply to the mortuary – particularly for refrigeration purposes – is to be provided from the essential supply system for the hospital. Alternatively, a back-up generator is to be supplied to allow for the maintenance of required temperatures in the cooling/freezing facilities in the mortuary.

 

#BIOLOGICAL SAFETY

#A Biosafety Laboratory Level 3 (BSL3) designation (R178-2012) is applicable for any decomposing bodies post-mortem area. This area is identified as a level-3 containment facility.

#BSL3 areas shall have restricted access and shall be separated from regular traffic flow routes.

#All doors opening into the BSL3 areas shall be appropriately labelled with biological safety hazard signage.

#Access to the BSL3 areas shall be through dedicated ventilated airlocks. A pressure differential of minimum +15Pa shall be maintained for the airlock relative to the BSL3 area. This pressure differential is relevant for when the doors are closed only. Room pressure differential gauges are to be fitted at the entrance to the BSL3 area.

#Airlock doors shall be interlocked such that only one door can be opened at a time, thereby preventing direct passage between the corridor and the BSL3 area.

#It is recommended <s>to create</s>that a transfer hatch be created for the transfer of goods between areas with differing biosafety-level classifications. This device shall be designed to preserve the integrity of the containment system and the mechanical ventilation design.

#Air exhausted from biosafety areas should be safely discharged to the outside with no chance for re-entrainment or contamination of other indoor spaces. Exhausts from biosafety areas should be vented at 3m above the roof level. Where such measures are not possible, exhaust air shall be EN1822 H13 HEPA filtered. Exhausts from biosafety areas should include anti-backflow devices.

 

#FINISHES TO FLOORS AND WALLS

#Walls and floor coverings within a mortuary should be easily cleanable and impervious to liquids and staining.

#Floors are to be of such a nature that they are not easily damaged by wheeled items that are moved over them. Vinyl floor coverings are not considered to be resilient enough for this purpose.

#Epoxy floor coverings are preferable, as these are easily maintained and do not have joints in them where liquids can accumulate to become a health risk.

#Corners between walls and floors shall be coved to facilitate the cleaning of these areas. These coving details should be solid and continuous without hidden formwork and cavities.

#Walls are to be coated with hard- wearing and washable materials/paint with provision made for trolley “bumpers” along walls exposed to high traffic. Wall coatings shall be impervious to damage from trolleys and mobile equipment.

#Materials such as vinyl sheeting should not be used to cover walls in wet areas. The risk of growth between the sheeting and the wall presents a health hazard to personnel working in the mortuary wet areas.

#Due to the potential presence of water on flooring it is essential that flooring be non-slip.

#Refer to the room requirement sheets herein and the '''''IUSS Materials and Finishes''''' guidance documents for further information.

#Surface- mounted services should be avoided to ensure smooth and washable surfaces. Where surface mounting of piping is unavoidable, this piping should be mounted on batons, such that the space behind the piping is readily accessible for cleaning.

 

#AUTOPSY EQUIPMENT/FIXTURES

#Equipment for the storage and transportation of bodies should meet environmental hygiene standards.

#In the majority of instances a<s>n</s> downdraft autopsy table is required within a hospital mortuary facility. This table should be one that is designed in such a way that there is a hot and cold water supply that is integral to table installation, as well as a drainage system that can automatically drain water/waste from the table to the sewer system of the facility.

#The autopsy table should have an integrated ventilation extraction or “downdraft” system in order to entrain noxious odours and infectious material that may emanate from a body. This can function to minimise the spread of any airborne pathogens from the body.

#Adequate stainless steel washing basins (at least one per autopsy table) must be provided in close proximity to the autopsy table for the use of personnel working in the facility.

#Electrical power must be provided from a 5 amp IPX5 waterproof single-socket outlet near the autopsy table to allow for the safe use of any electrical equipment that may be required during an autopsy.

#Lighting quality over the autopsy table must be exceptionally good. Refer to the lighting requirements specified in the room- requirement sheets herein and the '''''IUSS Building Engineering Services''''' guidance document for specifications.

#Adequately sized worktops must be provided along the walls of the autopsy area for equipment and specimens prior to storage.

#It is recommended that working surfaces of at least 500x2500mm be provided per autopsy table.

#A balance table for a bench-top scale is required. The scale can be either permanently mounted on the work surface or stored in the autopsy equipment store.

#A platform scale for measuring the weight of an entire body prior to any possible dissection/autopsy work being conducted is to be accommodated.

#Lockable <s>C</s>cabinets are required for the storage of autopsy equipment, as well as for any personal protective equipment morticians or medical examiners may require.

#Trolleys for the conveyance of bodies must be provided in the mortuary and adequate provision for the storage of these units must be available.

#The use of wood, such as for wooden doorframes, is not allowed in wet areas.

#Stainless steel bump rails or plates should be fitted in areas prone to damage from trolleys. These devices shall be fitted such that that they do not affect the integrity and cleanability of the walls and floors. These devices shall not create crevices or gaps which could <s>would</s> harbour pathogens or create a hygiene problem. Welded stainless steel sections shall be stainless steel Grade 316L

 

#VENTILATION

#<s>Mortuaries</s> Mortuary areas require good ventilation. The exhaust air is to be discharged to atmosphere such that it cannot be drawn back into the mortuary, any other ventilation inlet, or any indoor portion of the hospital.

#All external ventilation openings should be fly- and vermin- proof.

#Exhausted air may not pose a hazard to any person who is outside the mortuary. (See room-requirement sheets) Air exhausted from clinical areas should be safely discharged to outside with no chance for re-entrainment or contamination of other indoor spaces. Where these precautions are by no means possible, exhaust air shall be EN1822 H13 HEPA filtered.

#Sufficient ventilation is required for controlling noxious odours present in mortuaries and should also provide a means of protection to personnel working in the facility from possible airborne infections originating from corpses.

#Airborne- infection control is of particular concern and must be designed for in terms of the ventilation system. Tuberculosis, Hepatitis and HIV are <s>of</s> among the most regularly encountered diseases in mortuaries in South Africa and, as such, the spread of these pathogens beyond the mortuary, via a ventilation system, must be avoided by implementing the airborne- contamination control principles for high- risk areas in the ventilation system design. Refer to the '''''IUSS Building Engineering Services''''' guidance document for further guidance on airborne- contamination control principles.

#The ventilation system must be designed such that airborne pathogens that may be present in the body- holding area and autopsy room do not contaminate the remainder of the mortuary facility.

#No recirculation of air extracted from the clinical areas is permitted.

#Air from public areas, with the exception of viewing rooms, may be recirculated where this is in accordance with the National Building Regulations.

#Exhaust ventilation is to be designed in such a manner that this extracts from the areas with the highest risk of infection, while “clean” air is to be supplied into the lower- risk areas. This is to create a pressure cascade with cleaner areas being at a relatively higher air pressure than dirty areas.

#Air- supply registers should be at a high level and the extraction registers should be at a low level. The low- level extraction grilles shall not be more than 500mm above the finished floor level of the room <s>where</s> from which the extraction is taken <s>from</s>. Low- level air- register positions shall consider locations of water points and potential splashing during washing.

 

#AIR CONDITIONING

#The mortuary and autopsy area must have a temperature maintained <s>at</s> between 20˚C <s>to</s> and 21˚C.

#Public areas must be kept at a constant temperature between 23˚C and 25˚C.

#Air extracted from the mortuary may not be used for energy recovery or recirculation.

 

#REFRIGERATION EQUIPMENT DESIGN AND INSTALLATION

#All heat- rejection equipment associated with refrigeration in the body- storage facilities must be located on the outside of the mortuary, in a well-ventilated space at the rear of the fridge(s). Compressors installed on top of body cabinets on the inside of the mortuary are not acceptable. Heat build-up within the mortuary, as a result of this type of arrangement, potentially leads to equipment failure.

#Regularly serviced refrigeration equipment components should not be situated within the confines of the mortuary. Refrigeration technicians should not be required to climb onto or over a body cabinet to carry out any maintenance work. It is preferable to have refrigeration equipment situated in a separate ventilated area to the rear of the body cabinets. The designer is to refer to the selected heat- rejection equipment’s installation manual to determine free space and ventilation openings required around this equipment, since these details can vary between system types.

#Gauges indicating the temperature within the body cabinet must be clearly visible above the door of the unit in order that this can be readily monitored.

#The acceptable average temperature within a normal body cabinet or refrigerated room is between 2.0˚C and 6˚C. In instances where a body has to be kept for an extended period of time a cabinet temperature of at least -20˚C is required.

#In facilities where large quantities of bodies are kept, cold rooms for the storage of multiple bodies on trays are recommended.

#The materials used for the construction of the units are to be of stainless steel to facilitate cleaning and long-term maintenance of the equipment. Grade 316 stainless steel (18/10) is preferable over Grade 304 (18/8), as it offers better corrosion resistance'''.'''

#For welded stainless steel construction, Grade 316L or similar is required.

#If a facility is required to collect and retain forensic samples, refrigeration equipment should be provided for the preservation of these samples. Preferably this equipment should be placed in an area where <s>they</s> it can readily be secured from unauthorised access and tampering.

 

#SECURITY ARRANGEMENTS

#Due to the medical and legal nature of the contents of a mortuary, it is essential that a mortuary has good access control and security systems.

#Theft from mortuaries should be forestalled by, inter alia, constantly monitoring all entrances and preventing free access to mortuary areas. This is especially important for the body- storage areas. Access card or tag systems are open to misuse and are not an appropriate access- control measure. Combinations of tag and biometric access- control systems are recommended.

#Door closers with a “hold-open” mechanism should be installed on the mortuary room doors. This enables doors to close automatically with normal traffic, but can also be held open when moving equipment or trolleys through. “Crash”- type doors should be avoided as these are not easily cleanable and are subject to damage and abuse.

#It is recommended that a timed alarm be fitted to doors to ensure that they are closed shortly after any entrance or exit. This is to <s>mitigate</s> militate against the tendency of keeping doors open with some form of door stopper.

#Body cabinets are to be fitted with locks to prevent the unauthorised opening of these units to forestall the theft of any personal items of the deceased.

#In instances where historical problems relating to unauthorized entry into mortuaries is evident, it is recommended that closed-circuit TV systems be installed to help in monitoring and securing the facility.

PART C – Operation

#OBJECTIVES

The project planning, design, construction and commissioning should aim to provide:

#a safe, secure and functional environment for visitors and staff;

#low capital and ongoing operating costs (service, staffing and maintenance);

#an environmentally appropriate design solution; and

#a fully accessible, inclusive environment.

 

#HEALTH AND SAFETY

In light of the above it is essential that every effort be made to ensure that personnel working in the mortuary are provided with all required personal protective equipment (PPE), as this is essentially an area where pathogens could be present and present a health risk to staff. The following items should be available to staff as a minimum:

#Rubber aprons (or similar impervious material)

#Latex gloves (or similar impervious material)

#Mesh gloves in facilities where post mortems are performed

#Disposable gowns

#Safety glasses or full-face visors.

#Waterproof footwear

#Face masks

#Respirators with the appropriate filters must be available for use in high-risk situations.

#Storage space for PPE

No one should be permitted to enter the body storage and preparation areas without donning appropriate gowns and footwear.

#MAINTENANCE

When designing the facility, every effort must be made to limit the amount of maintenance that would be necessary to keep it in good condition. Seamless surfaces for walls and floors are critical, as this will reduce ongoing maintenance costs. The following minimum requirements should be complied with:

#Seamless floor coverings required

#Radiuses corners ??? required between floors and walls.

#No sharp corners on any work surfaces that could injure people working in the area.

#Ceilings to be readily cleanable.

#Work surfaces are to be impervious to liquids and resistant to staining and corrosion.

#Refer to the room- requirement sheets herein and the IUSS Materials and Finishes guidance documents for further information on the general requirements for materials and finishes.

#All equipment requiring calibration, such as fridges and scales, are to be attended to on an annual basis or when it is suspected that they are defective in respect of their expected/intended performance

PART D – User Room Requirements

Room-requirement sheets

Table 3: Accommodation schedule
{| class="wikitable"
|'''Room Name'''
|'''Service Description'''
 
|'''Area'''

'''(m²)'''
|'''Min. Ceiling Height'''

'''(m)'''
|'''Occupancy'''

'''(Persons)'''
|'''Nominal Utilisation per day'''

'''(hours)'''
|-
|Ablution areas
|Ablution areas – male and female

One WHB per WC or urinal
|3 (per cubicle)
|2.8
|1
|4
|-
|Shower facilities
|Shower facilities – male and female
|3 (per cubicle)
|2.8
|1
|2
|-
|Changing room
|Staff changing room - lockers to be provided
|8
|2.8
|2
|2
|-
|Storage space
|Equipment and PPE storage space
 
|8
|2.8
|1
|1
|-
|Offices
|Office space – interview, body receiving, pathologist
|9
|2.8
|2
|8
|-
|Body/bier room
|Area where a body can be laid out for viewing and identification
|9
|2.8
|1
|8
|-
|Viewing room
|Viewing room – external to body- layout area
|9
|2.8
|4
|1
|-
|Autopsy room
|Autopsy facility – Autopsy table with water supply and discharge and extraction ventilation. WHBs and stainless steel working surfaces
|27
|2.8
|3
|3
|}

'''Table 4: Room services sheet'''
 
{| class="wikitable"
|'''Room Name'''
|'''Temp'''

'''(°C)'''
|'''Ventilation'''

'''(AC/h)'''
|'''Ventilation'''

'''Type'''
|'''Pressure Relative to'''

'''Ambient'''
|'''Wet Services'''
|'''SSO'''

'''400V'''
|'''SSO'''

'''230V'''
|'''Task Illuminance'''

'''(lux)'''
|'''Data Points'''
|'''Colour Rendering'''

'''(Ra)'''
|-
|Reception area
|22-25°C
|2
|Forced supply
|=
|
|0
|0
|100 at floor level
|0
|80
|-
|Visitors ablution areas
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|WC,

WHB
|0
|0
|150 at floor level
|0
|80
|-
|Public waiting area
|22-25°C
|2
|Forced supply
|<nowiki>+ </nowiki>
|
|0
|0
|100 at floor level
|0
|80
|-
|Offices
|22-25°C
|2
|Forced supply/ recirc.
|=
|
|0
|2
|300 at desk level
|1
|80
|-
|Circulation Spaces
|22-25°C
|10
|Forced supply/ recirc.
|=
|
|0
|0
|200 at floor level
|0
|80
|-
|Viewing room
|22-25°C
|2
|Forced supply
|<nowiki>+ </nowiki>
|
|0
|0
|100 at floor level
|0
|80
|-
|Layout room
|20-21°C
|2
|Forced extraction
|<nowiki>- </nowiki>
|WHB
|0
|0
|300 at table level
|1
|80
|-
|Storage space
|22-25°C
|4
|Forced supply
|=
|
|0
|1
|200 at floor level
|0
|80
|-
|Mortuary
|20-21°C
|12
|Forced extraction
|<nowiki>- </nowiki>
|WHB,

FD
|0
|1
|200 at floor level
|0
|80
|-
|Mortuary plant area
|n/a
|n/a
|Natural ventilation
|=
|
|1
|1
|150 at floor level
|0
|80
|-
|Autopsy table
|20-21°C
|20
|Forced extraction
|<nowiki>- </nowiki>
|CW Faucet
|0
|1
|5200 at table level
|0
|90
|-
|Autopsy room
|20-21°C
|20
|Forced extraction
|<nowiki>- </nowiki>
|WHBs,

FD
|0
|2
|500 at floor level
|1
|90
|-
|Changing room
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|WHB
|0
|1
|150 at floor level
|0
|80
|-
|Staff ablution areas
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|WHB,

WC
|0
|0
|150 at floor level
|0
|80
|-
|Shower facilities
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|CW + HW

Faucet
|0
|0
|150 at floor level
|0
|80
|}

'''Table 5: Room finishes'''
 
{| class="wikitable"
|'''Room Name'''
|'''Floor'''

'''Material'''
|'''Wall / Floor Interface'''
|'''Walls'''

'''Finish'''
|'''Ceiling'''

'''Finish'''
|'''Glazing'''

'''Type'''
|'''WHB'''
|'''Doors'''

'''Type'''
|-
|Ablution areas (all)
|Jointless vinyl sheet
|Skirting coved and finished as per floor
|Ceramic wall tiles with epoxy grout
|Washable acrylic paint
|Obscure laminate safety glass
|1 per WC or urinal
|Solid wood with galvanised steel or stainless steel sheet trolley plates
|-
|Public waiting area
|Jointless vinyl sheet
|Coved vinyl skirting
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Lockable glazed entrance door
|-
|Changing room
|Jointless vinyl sheet
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Obscure laminate safety glass
|0
|Solid wood with galvanised steel or stainless steel sheet trolley plates
|-
|Storage space
|Jointless vinyl sheet
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood with galvanised steel or stainless steel sheet cladding
|-
|Offices
|Jointless vinyl sheet
|Coved vinyl skirting
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood
|-
|Body Room
|Self- levelling epoxy
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood
|-
|Viewing Room
|Self- levelling epoxy
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood
|-
|Autopsy Room
|Self- levelling epoxy
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Obscure laminate safety glass
|Min 1 per autopsy table
|Solid wood with galvanised steel or stainless steel sheet cladding
|-
|Circulation Spaces
|Jointless vinyl sheet
|Coved vinyl skirting
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|
|}
'''PART E – Examples and case studies'''

Figure 4 demonstrates the relationships between the zones within the mortuary. In this example it is evident how visitors are managed and kept out of the working portions of the mortuary through segregation in the internal layout. The process flow of the bodies into, through and out of the mortuary has been well considered in that the flow is linear with bodies entering the mortuary <s>on</s>at one end of the facility and exiting at the other. Unfortunately, the restrictions presented by the location of the mortuary, as can be studied in Figure 3, has forced the design into a number of compromises relating to the external flow and access to the mortuary. Staff access is quite severely compromised in being through the mortuary lobby. This mortuary lobby, in the absence of a dedicated preparation room, has the potential of being used as one. This arrangement may impact negatively on the dignity of some staff, the dignity of the deceased, and mortuary security.

Visitors’ access to the mortuary and their adjacent toilets is near the hearse bay and turning areas. There is no natural screening of this entrance from the activities in the hearse bay and it is not inconceivable that visitors may inadvertently wander into the wrong area and be exposed to operational activities not appropriate for the bereaved.

The door sizes of the body storage rooms seem too small for the easy passage of a body trolley when compared to the double doors made available for the passage of the body from there through the remainder of the facility. Door size selection should not be limited by the fact that these are cold room doors. Where doors are too small for free passage of trolleys and porters, <s>their</s> the doors’ service life would be severely shortened and any savings made on the door selection would be lost to maintenance or retrofitting an improved solution.

The access to the technical area for maintenance of the refrigeration equipment in this example meets the recommendations. Here technicians do not need to enter the mortuary to perform the majority of their work and these areas are quite well separated from the admin and visitors’ areas.

 

#EXAMPLE 2: LARGE MORTUARY WITH AUTOPSY FACILITIES

Figure 5 shows the layout of a standardised mortuary design. This is a large facility with autopsy capacity. Figure 6 has been presented in order to promote an understanding of the interrelationship between the various functional parts of the mortuary.

Considering the entrances shown in Figure 5, it is clear that the designer has <s>taken some</s>made an effort to screen the <s>visitor’s</s> visitors’ entrance from the hearses’ entrance. The staff entrance is also well positioned. The staff ablution<s>s</s> facilities and showers are located between the clinical areas and the admin areas. This arrangement encourages good segregation and gowning practice when moving between the mortuary activities and external movement.

The staff and visitors’ access positions are located well away from the working clinical areas of the mortuary and are also relatively remote from each other. This aids in improving security as it discourages the staff and visitors from using the wrong entrances and thereby assists in identifying persons who are present in areas where they do not belong.

This design doesn’t have a dedicated body prep area and it is assumed that the weighing and measuring area is therefore used for this purpose.

The large sliding doors of the cold room in this example can be compared to the cold-room doors in Figure 3 as an indication of what the door size should be like to enable easy passage.

The layout in this example does not provide for a dedicated exit yard and bodies and hearses entering and leaving the facility do so through the same entrance. This arrangement increases the potential for mistakes in body handling.

The common use of the bier room as access to the ID room seems to be a compromise resulting from the limited space provided for these rooms.

'''EXAMPLE 3: LARGE MORTUARY WITH AUTOPSY FACILITIES'''

The example shown in Figure 7<s>Figure 7</s> is a standard facility layout, very similar to that of Figure 5<s>Figure 5</s>, with the most notable changes being the inclusion of a dedicated vehicle- exit yard and the omission of the technical service area. The addition of the exit detail resolves the criticism of the arrangement in Example 2, while the omission of the technical service area for the refrigeration equipment could present an access problem for maintenance technicians, as discussed earlier in this document.

The example in Figure 7<s>Figure 7</s> has also resolved the compromises <s>to</s> in the arrangement of the bier rooms and ID/viewing rooms’ available space, discussed in the previous example.

'''DEFINITIONS'''

In the context of this document the following definitions pertain:
{| class="wikitable"
|'''Autopsy room:''' Synonymous with post–mortem examination area or suite.
|-
|'''Containment facility:''' The part within the demarcated zone in which the most malodorous activities occur. This facility includes the decomposing bodies’ post-mortem examination room, airlock ante room, and a decontamination unit each for men and women. The containment facility is sealed off from the rest of the demarcated area.
|-
|'''Demarcated area:''' The demarcated area, including the post-mortem examination rooms and all supporting functional spaces is the area where most sensitive, costly and specialised processes occur.
|-
|'''Dignity of deceased:''' The principle that bodies are treated with the respect and dignity befitting any person prior to death.
|-
|'''Dissection room or suite:''' Synonymous with post-mortem examination area or suite.
|-
|'''Mortuary:''' A mortuary is a facility for temporary storage of the deceased pending identification, medico-legal investigation and despatch.
|-
|'''Natural death:''' A death <s>by</s>from natural causes which <s>is</s> are determined to have been the cause of illness <s>of</s>or an internal malfunction of the body <s>which was</s> not caused by external forces.
|-
|'''Post-mortem examination area or suite''': A room and its attached service rooms designed for the performing of post-mortem examinations.
|-
|'''Post-mortem examination:''' Examination after death, which may include performance of an autopsy.
|-
|'''Unnatural death:''' A death which is not classified as being a '''''Natural Death'''''
|-
|'''Work bench (or bench):''' Unless otherwise specified, this is a surface ergonomically dimensioned for use from the standing position. This is normally 900mm.
|-
|'''Work-station:''' Unless otherwise specified, this is a surface ergonomically dimensioned for use from the seated position. This is normally 750mm. ??
|}

Page Break

'''BIBLIOGRAPHY'''

To be sorted out and made consistent - as advised to Mr Van Reenen
{| class="wikitable"
|REQUIREMENTS FOR THE FACILITIES AND OPERATION OF MORTUARIES (Second Edition 2009), NPAAC Tier 4 Standard. Australian Government Department of Health and Ageing.
|-
|MANAGING HEALTH AND SAFETY RISKS IN NEW ZEALAND MORTUARIES.(November 2000) Dr Chris Wells and Dr Jeff Brownless
|-
|Mortuary design and hazards. J. clin. Path. (1961), 14, 103
|-
|Health Authority Abu Dhabi. Part B- Version 3.1, June 2011
|-
|Design and layout of Mortuary Complex for a Medical College and Peripheral Hospitals. (2011) BasantLalSirohiwal, Paliwal PK, Luv Sharma and Hitesh Charlwa
|-
|Planning and design of modern mortuary complex in tertiary care. IIJFMT 4(1) 2006. Dr Sanju Singh, Dr U.S. Sinha, Dr A.K. Kapoor, Dr S.K. Verma, Dr Dalbir Singh, Dr Susheel Sharma
|-
|Australian Health Facility guidelines. Revision v.4.0 16-Dec-10
|-
|Mortuary Facilities – Design and improvement guide. CSIR March 2002
|-
|Project development brief for the new academic M6 pathology forensic laboratory. Western Cape Department of Health, August 2009
|-
|National Code of Guidelines for Forensic Pathology Practice in South Africa. Edited by NFPSC Academic Sub-committee 20 August 2007
|-
|IUSS Building Engineering Services guidance document
|}
{{Expand}}
[[Category:Procurement and Operation]]

Maintenance

2022-07-22T09:05:32Z

Tmojanaga: Adding text

Contents

OVERVIEW 5<s>6</s>

'''''Abbreviations''''' 9<s>8</s>

PART A – POLICY AND SERVICE CONTEXT 11<s>9</s>

Legislation, policies and international guidance 11<s>9</s>

1. LEGISLATIVE CONTEXT 11<s>9</s>

2. Further reference material and precedent<s>:</s> 11<s>9</s>

3. INFECTION PREVENTION AND CONTROL LEGISLATION 12<s>10</s>

4. BUILDING LEGISLATION 12<s>10</s>

5. SOUTH AFRICAN BUILDING PRACTICE POLICY AND GUIDELINES 12<s>10</s>

6. INTERNATIONAL DESIGN GUIDANCE 12<s>10</s>

Service Context 13<s>11</s>

PART B – PLANNING AND DESIGN 15<s>12</s>

1. INTRODUCTION 15<s>12</s>

2. LOCATION OF THE MORTUARY AND ACCESS ROUTES 16<s>13</s>

3. FACILITY CAPACITY 16<s>13</s>

4. SELECTING BODY STORAGE SYSTEMS 18<s>14</s>

5. FACILITY LAYOUT 18<s>15</s>

6. MORTUARY EQUIPMENT REQUIREMENTS 21<s>17</s>

7. MOVEMENT WITHIN A MORTUARY 22<s>18</s>

8. SERVICES REQUIRED 24<s>19</s>

9. BIOLOGICAL SAFETY 24<s>19</s>

10. FINISHES TO FLOORS AND WALLS 25<s>20</s>

11. AUTOPSY EQUIPMENT/FIXTURES 26<s>20</s>

12. VENTILATION 27<s>21</s>

13. AIR CONDITIONING 27<s>22</s>

14. REFRIGERATION EQUIPMENT DESIGN AND INSTALLATION 28<s>22</s>

15. SECURITY ARRANGEMENTS 28<s>22</s>

PART C – OPERATION 30<s>24</s>

1. OBJECTIVES 30<s>24</s>

2. HEALTH AND SAFETY 30<s>24</s>

3. MAINTENANCE 30<s>24</s>

PART D –USER ROOM REQUIREMENTS 32<s>32</s>

Room Requirement Sheets 32<s>32</s>

PART E – EXAMPLES AND CASE STUDIES 36<s>35</s>

Layout Examples 36<s>35</s>

1. EXAMPLE 1: SMALL MORTUARY ATTACHED TO HOSPITAL 38<s>36</s>

2. EXAMPLE 2: LARGE MORTUARY WITH AUTOPSY FACILITIES 39<s>37</s>

3. EXAMPLE 3: LARGE MORTUARY WITH AUTOPSY FACILITIES 43<s>40</s>

BIBLIOGRAPHY 46<s>42</s>

'''Table of Figures'''

Figure 1 Adjacency Diagram 1<s>16</s>

Figure 2: Access and Movement in a mortuary 1<s>18</s>

Figure 3 Example 1: Layout 1<s>35</s>

Figure 4 Example 1: Zoning & Access 1<s>36</s>

Figure 5 Example 2: Layout 1<s>38</s>

Figure 6 Example 2: Zoning and Access 1<s>39</s>

Figure 7 Example 3: Layout 1<s>40</s>

'''Table of Tables'''

Table 1 : IUSS Reference documents 8<s>7</s>

Table 2 Service Requirements 13<s>11</s>

Table 3 Accommodation Schedule 32<s>25</s>

TABLE 4 ROOM SERVICES SHEET 33<s>26</s>

TABLE 5 ROOM FINISHES 34<s>27</s>

''Version Control''
{| class="wikitable"
|''Template''
|''January 2013''
|''Tobias van Reenen''
|-
|''Discussion Draft 1''
|''February 2013''
|''Steve Fourie''
|-
|''Discussion Draft 5''
|''March 2013''
|''Steve Fourie''
|-
|''Discussion Draft 6''
|''May 2013''
|''Steve Fourie''
|-
|''Development Draft 1''
|''August 2013''
|''Tobias van Reenen''
|-
|''Development Draft 3.1''
|''February 2014''
|''Tobias van Reenen''
|-
|''Development Draft 3.1''
|''February 2014''
|''Prof J Vellema''
|}

Page Break

OVERVIEW

This document outlines the policy and service context and attempts to illustrate the desired planning principles and design considerations for mortuary services.

*''Part A'' outlines the South African legislation, policies and international guidance reference documents and the service context with respect to mortuary services;
*''Part B'' Planning and design;
*''Part C'' operation;
*''Part D'' user room requirements; and
*''Part E'' provides case studies.

Parts D and E are intended to demonstrate how the principles prescribed in Part A, B, and C can be applied in worked examples. Part D, if used directly, are deemed<s>-</s> to<s>-</s> satisfy the principles developed in Part B, but are not the only acceptable solutions.

Case studies (Part E) provide illustrative worked solutions and should not be adopted without appropriate contextual adaptation.

While this document outlines design requirements and acceptance criteria which have an impact on clinical services, these requirements are prescribed within the framework of the entire IUSS set of guidance documents and cannot be viewed in isolation. The following documents should be complied with, together with this document:

*IUSS: Regulations
*IUSS: Project Planning and Briefing
*IUSS: Environment and Sustainability
*IUSS: Hospital Design Principles
*IUSS: Infection Prevention and Control

Page Break

The following table identifies additional IUSS guideline documents which are recommended for reading in conjunction with this guideline.

'''Table 1 : IUSS Reference documents'''
{| class="wikitable"
|

'''CLINICAL'''

'''SERVICES'''
 
|Essential
|Recommended
|'''SUPPORT'''

'''SERVICES'''
|Essential
|Recommended
|'''HEALTHCARE ENVIRONMENT/ CROSSCUTTING ISSUES'''
|Essential
|Recommended
|'''PROCUREMENT'''

'''& OPERATION'''
|Essential
|Recommended
|-
|Adult Inpatient Services
|
|X
 
|Administration and Related Services
|
|
|Generic Room Requirements
|
|
|Integrated Infrastructure Planning
|
|
|-
|Clinical and Specialised Diagnostic Laboratory Guidelines
|
|X
|General Hospital Support Services
|
|X
|Hospital Design Principles
|
|
|Briefing Manual
|
|X
|-
|Mental Health
|
|
|Catering Services for Hospitals
|
|
|Building Engineering Services
|X
|
|Space Guidelines
|
|
|-
|Adult Critical Care
|
|
|Laundry and Linen Department
|
|X
|Environment and Sustainability
|
|
|Cost Guidelines
|
|
|-
|Emergency Centres
|
|
|Hospital Mortuary Services
|
|
|Materials and Finishes
|X
|
|Procurement
|
|
|-
|Maternity Care Facilities
|
|
|Nursing Education Institutions
|
|
|Future Healthcare Environments
|
|X
|Commissioning Health Facilities
|X
|
|-
|Adult Oncology Facilities
|
|
|Health Facility Residential
|
|
|Healthcare Technology
|
|
|Maintenance
|X
|
|-
|Outpatient Facilities
|
|X
|Central Sterile Service Department
|
|
|Inclusive Environments
|
|
|Decommissioning
|X
|
|-
|Paediatrics and Neonatal Facilities
|
|
|Training and Resource Centre
|
|X
|Infection Preventive Control
|X
|
|Capacity Development
|
|
|-
|Pharmacy
|
|
|Waste Disposal
|
|X
|Health Informatics
|
|
|
|
|
|-
|Primary Health Care Clinics and CHCs
|
|
|
|
|
|Regulations
|
|
|
|
|
|-
|Diagnostic Radiology
|
|
|
|
|
|
|
|
|
|
|
|-
|Adult Physical Rehabilitation
|
|
|
|
|
|
|
|
|
|
|
|-
|Sub-acute services
|
|
|
|
|
|
|
|
|
|
|
|-
|Facilities for Surgical Procedures
|
|
|
|
|
|
|
|
|
|
|
|-
|TB Services
|
|
|
|
|
|
|
|
|
|
|
|}

'''''Abbreviations'''''
{| class="wikitable"
|ACH
|Air changes per hour
|-
|ASHRAE
|American Society of Heating, Refrigerating, and Air-Conditioning Engineers
|-
|BMS
|Building Management System
|-
|BSL
|Biological safety level
|-
|CDC
|Centers for Disease Control (USA)
|-
|CSIR
|Council for Scientific and Industrial Research
|-
|FD
|Floor drain
|-
|FPS
|Forensic Pathology Service
|-
|HVAC
|Heating Ventilation Air Conditioning
|-
|HBA
|Hazardous biological agents
|-
|HCS
|Hazardous chemical substances
|-
|HEPA
|High efficiency particulate air filters
|-
|IPC
|Infection prevention and control
|-
|ISO
|International Standards Organisation
|-
|MDR TB
|Multi-drug resistant TB
|-
|NDoH
|National Department of Health
|-
|NBR
|National Building Regulations
|-
|<s>NDoH</s>
|<s>National Department of Health</s>
|-
|NHS
|National Health Service (UK health service)
|-
|NIOSH
|National Institute of Occupational Safety and Health (US agency)
|-
|O&M
|Operating and Maintenance (manual)
|-
|OHS
|Occupational health and safety
|-
|OQ
|Operational qualification
|-
|PGWCDoH
|Provincial Government Western Cape Department of Health
|-
|PPE
|Personal protective equipment
|-
|PQ
|Performance qualification
|-
|RDS
|Room data sheets
|-
|RH
|Relative humidity
|-
|SABS
|South African Bureau of Standards
|-
|SAO
|Senior Administrative Officer
|-
|SAPS
|South African Police Service
|-
|SI
|<s>Le Systeme International d' Unites</s> Le Système International d’Unités
|-
|SOP
|Standard Operating Procedures
|-
|SS
|Stainless steel
|-
|TB
|Tuberculosis
|-
|WC
|Toilet
|-
|WHB
|Wash-hand basin
|-
|WHO
|World Health Organisation
|-
|XDR TB
|Extreme (or extensively) <s>-</s>drug- resistant TB
|-
|
|
|-
|
|
|-
|
|
|}
PART A – Policy and service context

Legislation, policies and international guidance
 

#LEGISLATIVE CONTEXT

The following documents, as amended (though not an exhaustive list) pertain and contain an additional resource of information which would supplement and provide the basis of a design brief. A finer sense of standard operating procedures and legislative context is likely to inform and enhance the design process, so the professional teams are encouraged to use these as an additional resource:
 

*Inquest Act<s>,</s> 58, 1959
*National Health Act<s>,</s> 61, 2003
*Government Notice R363, 2013 [Regulations relating to the management of human remains]
*Government Notice R178, 2012 [Regulations relating to the registration of microbiological laboratories and the acquisition, importation, handling, maintenance and supply of human pathogens]

*Health Professions Amendment Act, 29, 2007
*Criminal Procedures Act<s>,</s> 51, 1977
*Births and Deaths Registration Act<s>,</s> 51, 1992
*National Environmental Management: Waste Act<s>,</s> 59, 2008
*National Archives of South Africa Act<s>,</s> 42, 1996

*Regulations regarding the Rendering of Forensic Pathology Service, ''Government Gazette'' No 30075. No R636, 20 July 2007
*Space Planning Norms and Standards for Office Accommodation used by Organs of State, ''Government Gazette'' No 27985. No 1665, 2 Sept 2005
*Western Cape Health Care Waste Management Draft Bill
*Municipal by<s>-</s>laws, as applicable
*National Code of Guidelines for Forensic Pathology Practice in South Africa, 20 Aug 2007

*Standard Operating Procedures, Forensic Pathology Service, PGWCDoH, 2006
*Biosafety in Microbiological and Biomedical Laboratories, U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention and National Institutes of Health, Fifth Edition, <s>2007</s> US Government Printing Office, Washington: 2007

 

#Further reference material and precedent<s>:</s>

 

*Standard specification for air-conditioning and ventilation systems, Western Cape Department of Public Works, 1998
*Fire security: a guide for architects, Western Cape Department of Public Works, 1998
*Standard electrical specification, South African Department of Public Works, 2005
*Facilities for mortuary and post-mortem room services, NHS Estates, 2001, ISBN 0-11-322000-00
*Part B – Health facility briefing and planning, Australasian Health Facilities Guidelines, 2007

*CKS 336: 2013 Mortuary Trolleys - SABS

#INFECTION PREVENTION AND CONTROL LEGISLATION

The National Infection Prevention and Control Policy and Strategy document makes specific reference to certain Acts and their relevant regulations, which bear relevance to the development and implementation of these health facility guidelines. These are:

*The South African Constitution, 1996 [Sections 2, 24, 27, 36 and 39], as amended
*The Occupational Health and Safety Act of 1993, Act No 85 of 1993 [Section 8(1)]

*Government notice R1390 of 27 December 2001 [Hazardous Biological Agents Regulation] as promulgated under Section 43 of the Occupational Health and Safety Act of 1993
*Government notice R908 of 27 June 2003 [Hazard Analysis Critical Control Point Regulation] as promulgated under Section 15(1) of the Foodstuffs, Cosmetic and Disinfectants Act of 1972
*The Environmental Conservation Act of 1989, Act No 73 of 1989
*The Foodstuffs, Cosmetic and Disinfectants Act of 1972, Act No 45 of 1972

 

#BUILDING LEGISLATION

The following legislation and regulations impact and provide guidance on the provision and design of health care facilities as above:

*The National Environmental Management Act 107 of 1998, as amended
*Building regulations and Building Standards Act 103 of 1977, as amended
*National Building Regulations; SANS 10400:2010, Code of Practice for the Application of the National Building Regulations

*Promotion of Equality and Prevention of Unfair Discrimination Act No 4 of 2000
*General Procedures and Loadings adopted in the Design of Buildings, SABS 0160, 1993
*Structural Use of Concrete Design, SABS 0100-1, 1992
*Structural Use of Concrete – Materials and Execution of Work, SABS 0100-2, 1992
*Specification for Civil Engineering Construction SABS 1200

 

#SOUTH AFRICAN BUILDING PRACTICE POLICY AND GUIDELINES

*R158 of 1980 regulations pertaining to Private Hospitals and Unattached Operating Theatres – R198
*Good Pharmacy Practice, Board Notice 129 of 2004, as amended [see Chapter 1].

#INTERNATIONAL DESIGN GUIDANCE

*ASHRAE Standard 52.2, “Method of Testing General Ventilation Air-Cleaning Devices for Removal Efficiency by Particle Size”, 1992, 1999b
*ASHRAE Standard 62, “Ventilation for Acceptable Indoor Air Quality”, 1989
*ASHRAE. “HVAC Design Manual for Hospitals and Clinics, 2003”, 1989
*CIBSE Applications Manual AM10:1997 “Natural Ventilation in Non-Domestic Buildings”, 1998
*CIBSE Applications Manual AM13:2000 “Mixed Mode Ventilation,” 2000

*ASHRAE Standard 170, “Ventilation of Health Care Facilities”, 2008
*QASA. “Know Your Rights” [Accessibility & the Built Environment]
*Department of Health and Human Services. “Environmental Control for Tuberculosis: Basic Upper-Room Ultraviolet Germicidal Irradiation - Guidelines for Healthcare Settings”, 2009
*WHO. “WHO Policy on TB Infection Control in Health-Care Facilities, Congregate Settings and Households”, 2009

Guidance has also been provided by AIA (USA), NHS (UK), and Australian Health Facility Guidelines on Healthcare Building Design. Additional references can be sourced from www.tb-ipcp.co.za

Service Context

The following table gives an indication of the service requirements for mortuaries within different types of public hospitals.

Table 2: Service Requirements
{| class="wikitable"
|'''Service'''
|'''District'''
|'''Regional'''
|'''Tertiary'''
|'''Central'''
|'''Specialised'''
|-
|Small (beds)
|50-150
|Min 300
|Min 400
|
|
|-
|Medium (beds)
|150-300
|
|
|
|
|-
|Large (beds)
|300-600
|Max 800
|Max 800
|Max 1200
|Max 600
|-
|Training
|Where practical
|Where practical
|Optional
|Yes. Attached to medical school
|
|-
|Conduct research
|
|
|
|Yes
|
|-
|'''Mortuary'''
|
|
|
|
|
|-
|Short-term stay (2˚C)
|Yes
|Yes
|Yes
|Yes
|
|-
|Long-term stay (-15˚C)
|Yes
|Yes
|Yes
|Yes
|
|-
|Autopsies (20°C -21°C)
|Yes
|Yes
|Yes
|Yes
|Yes
|}

For the determination of capacity requirements of mortuaries refer to the recommendations further on in this document.

This guidance document relates to mortuaries located within and serving hospitals, with respect to persons that die due to natural causes in that hospital. This document excludes mortuaries <s>exclusively</s> dealing exclusively with cases that require medico-legal investigation of deaths from unnatural causes.

Post mortems conducted in hospital mortuaries should be limited to conducting investigations and procedures where no medico-legal investigation is required and death from natural causes is suspected.

Hospital deaths from natural causes and those suspected to be of unnatural cases should not be managed in the same facility unless the hospital mortuary is equipped to comply with the specific legal requirements as <s>it</s> they relate<s>s</s> to the chain of evidence, etc. The requirements for forensic- pathology service mortuaries are not exhaustively detailed in this document.

It is also noted that some hospitals may opt to contract out the removal and storage of decedents to private undertakers and these hospitals may <s>only</s> require only the minimum in terms of refrigerated body storage.

PART B – Planning and Design

#INTRODUCTION

#All state- run mortuary facilities fall within the domain of the Department of Health, both National and Provincial;<s>,</s> and in an effort to provide engineers and architects who are required to either design new facilities or upgrade existing facilities, this document provides the minimum standards necessary to comply with existing legislation.

#This document will provide designers of this type of facility with guidelines as to what is required in terms of the following:

*Type of service and package of care being provided
*Mortality rate
*Access and egress
*Discreet management of human remains

*Size and dimensions of the actual facility
*Positioning of mortuaries within hospitals
*Finishes of surfaces in these facilities
*Water- supply requirements
*Drainage requirements

*Electrical supply and lighting requirements
*Installation requirements for equipment and services
*Body-storage requirements
*Body-handling facilities
*Body-holding areas

*Body-viewing area
*Autopsy equipment (tables)
*Air conditioning and ventilation requirements (for infection and indoor air quality control)
*Security of the facility

#In addition to the items listed above, it is also necessary to consider the needs of visitors to these facilities, particularly those wishing to, or who are required to, identify bodies. In line with this it is also necessary to take the handling of bodies into consideration as it pertains to issues of patient dignity.

#Forensic pathology mortuaries are not <s>considered</s> exhaustively described in this document, although the majority of mortuaries do have basic facilities for general autopsies that are not necessarily medico-legal in nature. A forensic pathology mortuary has laboratory facilities attached that are outside the scope of regular mortuaries found in hospitals and at police stations. It should be noted that there are a number of principles that hold true for both hospital and forensic pathology mortuaries.

#Compliance with the requirements of the Occupational Health and Safety Act (Act 85 of 1993 as amended) are to be complied with at all times during the design of a mortuary.

 

#LOCATION OF THE MORTUARY AND ACCESS ROUTES

#The position of the mortuary in a hospital should be such that the mortuary is easily accessible to mortuary staff and related service providers without presenting either aesthetic, emotional or ethical problems for unrelated hospital staff, patients or visitors. Visitors to the mortuary, however, should be provided with clear and direct access to the mortuary upon arrival at the hospital, without having to travel unnecessarily through hospital departments.

#Where bodies are moved into or out of the mortuary, they should not be moved through general public-access areas. Appropriate routes would include technical service or goods corridors and through the hospital’s support services yard.

#Special considerations should be given to plans for contingency access to the mortuary in the event of case- load surges, which may <s>be</s> result from disasters.

#Bodies should not be held for any period in any locations between the body- holding rooms within clinical areas and the mortuary.

#Where a mortuary unit is used jointly between the hospital and the local authority it is beneficial for the mortuary to be in a building separate from the main hospital building.

#The delivery of bodies to the mortuary and their subsequent removal from the facility is to be such that it is carried out in a manner that is not visible to the general public, preferably in a covered and enclosed area.

#While siting and access are important aspects when locating a mortuary, it is also important to provide the mortuary with pleasant surroundings in order to promote the dignity of those working in or visiting the mortuary.

 

#FACILITY CAPACITY

#The layout and size of a mortuary is largely determined by the number of bodies stored and whether body storage needs to be in cabinets or in refrigerated rooms.

#In order to determine the storage capacity of a hospital mortuary it is recommended that historical data, where available, should be used. In the South African context it is suggested that a storage capacity of between 5 and 10 bodies per 100 beds should be used. This varies with the rural or urban location of the facility. This capacity should not take into account the need to store bodies from deaths which are not hospital related, typically motor-vehicle accident deaths and deaths from criminal activity. Requirements for contingency storage capacity related to disaster management should be considered.

#The body storage capacity required can be estimated on the basis of the number of deaths per year in the hospital, the length of time of holding and the required body store occupancy rate. The number of body trays can be calculated from Equation 1<s>Equation 1</s> below.

-Equation 1

Where:

BT = Number of body trays

D = Number of deaths per year requiring body trays

S = Average length of stay (in days)

R = Required body tray occupancy rate

[Text Box]

#The estimated storage capacity for bodies in a mortuary could be confounded by a number of local factors, such as:

*Mortality rate from natural causes.
*Mortality rate from infectious disease. (Highly contagious disease deaths require special storage facilities.)

#Where the hospital is expected to place the body in cold storage until collection by forensic pathology services the following additional factors should be considered:

*Mortality rate from foul play.
*Mortality rate from traffic incidents.

 

#SELECTING BODY-STORAGE SYSTEMS

#Body-storage systems are principally divided into refrigerated rooms or body cabinets. Differences within these system types occur where specific temperatures or sizes are required based on risk, need and capacity requirements.

#Where a system of functionally separate body cabinets is selected, this system would have an inherent redundancy against failure, as the failure of a single unit would not necessarily imply a system failure. In contrast, a refrigerated room would require less maintenance and would have a lower frequency of failure; however a single component failure could be critical if standby condensing units are not installed. For this reason, multiple- cabinet systems are recommended for areas where expected maintenance response times would negatively affect the mortuary’s operations.

#It is possible to have a requirement for a mixture of refrigerated rooms and body cabinets. This could be affected by local cultural requirements such as for families <s>which</s> who object to bodies sharing storage space, the case load of the facility or the case profile.

#Where there is a requirement for the long-term storage of bodies, these are to be kept at a lower temperature than would be the case in a refrigerated room. In this instance separate body cabinets are required. Long- term storage of bodies is most often required when an indigent person dies and difficulty is experienced in locating the next of kin, as the person cannot legally be buried until this process has been completed.

#In general, smaller facilities rely on body cabinets for the storage as these facilities do not have the space or the need for the large-scale storage of bodies, <s>and they do not</s>they would not appreciate the functional flexibility offered by these systems. By rule of thumb, any facility that has the requirement to store <s>less</s> fewer than 12 bodies at any given time should use body cabinets. This <s>provides</s> gives the option of providing both short- and long-term storage with the smallest facility and equipment footprint.

#Bodies suspected of having succumbed to a highly contagious and dangerous disease require special treatment. These should be stored in such a manner that they do not present a hazard to personnel working in the mortuary. Typically these bodies should be stored at the same temperature<s>s</s> <s>the same</s> as <s>for</s> long- stay bodies, e.g. -15˚C, and should be placed in hermetically sealed plastic body-bags.

#Provision for the secure cold storage of body parts should <s>also</s> be provided.

 

#FACILITY LAYOUT

#As mentioned, the layout and size of a mortuary is going to be largely determined by case load and whether storage is in cabinets or refrigerated rooms. It is acceptable to have a mixture of refrigerated rooms and body cabinets.

#In a mortuary facility there are a number of separate areas that need to be considered other than the body- storage areas. These include:

#'''Reception area''' for members of the public who are required to visit the mortuary on official business – typically to identify bodies or to pay their last respects to a deceased person.

#'''Ablution areas''' for staff. Where unisex ablutions are provided it is recommended that <s>the</s> no urinal is provided.

#<s>'''Visitor’s'''</s> '''Visitors’ admin space''' close to the reception area, where any admin or official business related to the identifying of a body can be completed.

#'''Staff admin space''' close to the point where a body is delivered to the mortuary, so that pertinent documentation can be completed – both with respect to the delivery of the body, as well as when the body is released from the mortuary again.

#'''Office space''' for pathologists to write up reports <s>for</s> in instances where this could be required. This is dependent on the size of the mortuary as small facilities would not require a separate room(s) for this function.

#'''Waiting''' and circulation areas for visitors to the mortuary.

#'''Viewing room,''' from where a body can be viewed through a curtained glass window between this space and the body- display room.

#'''Body- display''' room, where a body is placed for identification purposes. There is to be access to this area via a lockable door to the viewing room <s>for</s> in instances where it is necessary for non-mortuary personnel to have direct access to a body in the viewing room. There is to be access to this room from the body- storage area to allow bodies to be brought in for display purposes.

#'''Body preparation''' area, where a body that is delivered to the mortuary needs to be attended to prior to it being placed in the viewing room.

#'''Shower facilities''' (staff)

#'''Changing room''' (staff)

#'''Storage space''' for equipment and clothing that is worn in the body-preparation and autopsy spaces.

#'''Body-storage''' facility (cold room or refrigerated cabinets), depending on the length of time that bodies are expected to be kept in the facility.

#'''Autopsy facility,''' where the cause of death can be determined. This facility will differ from mortuary to mortuary, depending on whether forensic or standard medical autopsies to determine the cause of death are conducted.

[GroupDrawing]
 

#Figure 1<s>Figure 1</s> is an example of an adjacency diagram for a typical mortuary. In this instance the proximity also relates to visual and physical access. It is also understood that not all mortuaries would require all of the spaces indicated in this diagram, and that some of the spaces shown as being '''''immediately adjacent''''' could be included as a single area if functionality and privacy considerations permit it.

#There remains abundant scope for variations in the planning of the layouts making up the mortuary. and the hospital architect should consult with all stakeholders to arrive at an ideal solution.

#When developing the facility layout, careful consideration should be given to the routes through the facility of staff, bodies and visitors. These routes should overlap as little as possible and there should never be a common entrance for bodies and staff or visitors.

#The room requirement sheets are presented in ''PART D – User Room Requirements<s>PART D –User Room Requirements</s>''of this document.

#Storage space for body lifts must be provided.

#Suitable sluicing facilities are required to be able to clean equipment and fabrics after completion of any work in the mortuary facility.

 

#MORTUARY EQUIPMENT REQUIREMENTS

#Equipment for storage and transportation of bodies should meet environmental hygiene standards.

#For mortuary trolley design and supply, the SABS published standard '''''CKS336:2013 Mortuary Trolleys''''' is recommended. It should be noted that this is not a normative South African National Standard, and individual requirements may differ.

#'''Body-cabinet''' selection and installation requires the following considerations:

#Three-level body cabinets could be selected which have a single door to give access to all of the body trays, for instances where separation between bodies is required. Alternatively, cabinets that provide a single door for access to all the body trays are acceptable.

#It is critical that bariatric (obese) bodies are catered for in each cabinet. The lowest-level tray should be designed for this purpose.

#Special consideration is to be given to the provision of capacity for storage of juvenile and infant decedents. The handling of these bodies is an especially sensitive and emotive issue, and separate storage in dedicated cabinets is recommended.

#Body lifts must be supplied to facilitate the loading of bodies into and removal of bodies from the cabinets. Body lifts help to preserve dignity when handling bodies, while at the same time making it easier and safer for mortuary personnel to handle bodies.

#A clear space must be provided in front of the body cabinets to allow for the placing of a corpse into the cabinets. It is recommended that there be at least a 3m clearance between the front of the cabinet and any fixed structure. This is to accommodate whatever means of conveyance is used to transport a corpse to ?? and then load it into the cabinet.

#Due to the vast array of cabinets available on the market and the lack of an appropriate national standard, it is not yet possible to prescribe sizes for refrigerated cabinets in this guide.

#The required cabinet size is fundamental when designing a mortuary. Where space is not too limited and there are no indications that there may be cultural concerns relating to the storage of bodies together in a cold room, it is recommended that cold rooms be used. Cold rooms offer space savings when compared to cabinets.

#A temperature gauge must be installed close to the door of the facility to indicate the storage-space temperature. This gauge should have an alarm system connected to it to give a warning should there be an unacceptable rise in temperature in the storage space. Typically, if the temperature should rise more than 2˚C above the set temperature, an alarm should be activated at a point that is manned at all times.

#Body cabinets and refrigerated rooms must be supplied with electrical power from the hospital’s essential services electrical supply.

#A slop hopper is to be provided to allow for the cleaning of the body preparation and autopsy areas, in particular after the completion of any work carried out in these areas.

#To allow for the rinsing of body parts and organs, during an autopsy procedure it is important that suitable basins be provided in close proximity to <s>the</s>a downdraft autopsy table.

#Where there is transition between “clean” and “dirty” areas, provision is to be made to allow for the cleaning of footwear in a “transitional” area. This helps prevent the transport of contaminants from dirty areas.

 

#MOVEMENT WITHIN A MORTUARY

#Movement of members of the public visiting the mortuary is to be restricted such that they do not have access to the body- preparation or autopsy areas. (Figure 2<s>Figure 2</s>)

#The facility must be available within the mortuary where body identification can be conducted in a private and dignified manner. This viewing area should consist of a body- display or layout room with an adjacent viewing room, where the body can be viewed through a curtained shatter-proof glass window.

#The requirement for a viewing and identification area also pertains to hospitals which outsource their mortuary services.

#The viewing room and visitors’ admin rooms should be designed such that counselling can be conducted in a pleasant environment for bereaved persons.

#The design of the viewing facility should allow <s>for</s> adequate space for persons to view a body in a dignified manner.

#Direct access to the body- layout room from the viewing room is to be provided via a lockable door, to allow visitors access to the body.

#Ablution facilities are to be available to members of the public who are required to visit the mortuary complex.

#[GroupDrawing]Where a dedicated room, as described above, cannot be allocated for placing a body for viewing purposes, the persons who are viewing a body should be given a private space for viewing the body through a curtained shatter-proof glass window, as a minimum.

#Adequate facilities to accommodate at least 7 visitors are to be provided.

#Staff access to the mortuary facility is to be separate from the general public. (Figure 2)

#Mortuary staff change rooms should be provided with secure lockers for storage of street garments, lab coats, personal protective equipment and valuables. <s>Street garments and lab garments</s>

#Mortuary staff may have completely separate ablution facilities from those used by the general public requiring access to the mortuary facility.

#In a free- standing mortuary building the delivery to and removal of bodies from the facility may be via the same access point to the building.

#A mortuary that forms an integral part of a hospital will require separate routes for receiving bodies and the subsequent removal thereof.

#In the unusual event that a body arrives from outside <s>of</s> the hospital, the normal route of removal should be used for receipt of the body.

#A clear distinction is to be made between “clean”,” “dirty” / “wet” and “transitional” areas. This is best achieved by creating a physical “RED LINE” on the floor indicating the separation of these areas, with “yellow lines” used to demarcate “transitional” areas. Receptacles for the collections of dirty clothing, etc, must be made available at the transition area from <s>a</s> dirty to clean areas and in change rooms.

#A well-drained facility for washing <s>of</s> vehicles which have been contaminated with decomposed bodies or <s>bodily</s> body fluids should be provided in an enclosed area, near to the mortuary.

 

#SERVICES REQUIRED

#Hygienic floor drains that are resistant to corrosion from blood and chlorine should be provided in all “wet areas” of the mortuary and should be directly connected to the sewer system. These areas include body preparation, autopsy space, etc. These areas require thorough cleaning after every procedure, using large quantities of water and decontaminating and disinfecting chemicals and soaps.<s>.</s>

#Sluicing facilities are to be provided in both the body- preparation and autopsy areas if they are not a common area.

#Open floor channels should be avoided. Where this is not possible, these should be covered by durable, flush- fitted stainless steel grids.

#No sewer connections external to the mortuary services should be made to the line between the wet area drains and the main sewer system in order to prevent backflow to other areas.

#The provision of hot and cold water in the facility is imperative, with all basins, sinks, ablution areas and autopsy tables being provided with both.

#Anti-backflow devices should be fitted to the water- supply lines serving mortuary table faucets to prevent backflow should supply water pressure fail.

#Electricity supply to the mortuary – particularly for refrigeration purposes – is to be provided from the essential supply system for the hospital. Alternatively, a back-up generator is to be supplied to allow for the maintenance of required temperatures in the cooling/freezing facilities in the mortuary.

 

#BIOLOGICAL SAFETY

#A Biosafety Laboratory Level 3 (BSL3) designation (R178-2012) is applicable for any decomposing bodies post-mortem area. This area is identified as a level-3 containment facility.

#BSL3 areas shall have restricted access and shall be separated from regular traffic flow routes.

#All doors opening into the BSL3 areas shall be appropriately labelled with biological safety hazard signage.

#Access to the BSL3 areas shall be through dedicated ventilated airlocks. A pressure differential of minimum +15Pa shall be maintained for the airlock relative to the BSL3 area. This pressure differential is relevant for when the doors are closed only. Room pressure differential gauges are to be fitted at the entrance to the BSL3 area.

#Airlock doors shall be interlocked such that only one door can be opened at a time, thereby preventing direct passage between the corridor and the BSL3 area.

#It is recommended <s>to create</s>that a transfer hatch be created for the transfer of goods between areas with differing biosafety-level classifications. This device shall be designed to preserve the integrity of the containment system and the mechanical ventilation design.

#Air exhausted from biosafety areas should be safely discharged to the outside with no chance for re-entrainment or contamination of other indoor spaces. Exhausts from biosafety areas should be vented at 3m above the roof level. Where such measures are not possible, exhaust air shall be EN1822 H13 HEPA filtered. Exhausts from biosafety areas should include anti-backflow devices.

 

#FINISHES TO FLOORS AND WALLS

#Walls and floor coverings within a mortuary should be easily cleanable and impervious to liquids and staining.

#Floors are to be of such a nature that they are not easily damaged by wheeled items that are moved over them. Vinyl floor coverings are not considered to be resilient enough for this purpose.

#Epoxy floor coverings are preferable, as these are easily maintained and do not have joints in them where liquids can accumulate to become a health risk.

#Corners between walls and floors shall be coved to facilitate the cleaning of these areas. These coving details should be solid and continuous without hidden formwork and cavities.

#Walls are to be coated with hard- wearing and washable materials/paint with provision made for trolley “bumpers” along walls exposed to high traffic. Wall coatings shall be impervious to damage from trolleys and mobile equipment.

#Materials such as vinyl sheeting should not be used to cover walls in wet areas. The risk of growth between the sheeting and the wall presents a health hazard to personnel working in the mortuary wet areas.

#Due to the potential presence of water on flooring it is essential that flooring be non-slip.

#Refer to the room requirement sheets herein and the '''''IUSS Materials and Finishes''''' guidance documents for further information.

#Surface- mounted services should be avoided to ensure smooth and washable surfaces. Where surface mounting of piping is unavoidable, this piping should be mounted on batons, such that the space behind the piping is readily accessible for cleaning.

 

#AUTOPSY EQUIPMENT/FIXTURES

#Equipment for the storage and transportation of bodies should meet environmental hygiene standards.

#In the majority of instances a<s>n</s> downdraft autopsy table is required within a hospital mortuary facility. This table should be one that is designed in such a way that there is a hot and cold water supply that is integral to table installation, as well as a drainage system that can automatically drain water/waste from the table to the sewer system of the facility.

#The autopsy table should have an integrated ventilation extraction or “downdraft” system in order to entrain noxious odours and infectious material that may emanate from a body. This can function to minimise the spread of any airborne pathogens from the body.

#Adequate stainless steel washing basins (at least one per autopsy table) must be provided in close proximity to the autopsy table for the use of personnel working in the facility.

#Electrical power must be provided from a 5 amp IPX5 waterproof single-socket outlet near the autopsy table to allow for the safe use of any electrical equipment that may be required during an autopsy.

#Lighting quality over the autopsy table must be exceptionally good. Refer to the lighting requirements specified in the room- requirement sheets herein and the '''''IUSS Building Engineering Services''''' guidance document for specifications.

#Adequately sized worktops must be provided along the walls of the autopsy area for equipment and specimens prior to storage.

#It is recommended that working surfaces of at least 500x2500mm be provided per autopsy table.

#A balance table for a bench-top scale is required. The scale can be either permanently mounted on the work surface or stored in the autopsy equipment store.

#A platform scale for measuring the weight of an entire body prior to any possible dissection/autopsy work being conducted is to be accommodated.

#Lockable <s>C</s>cabinets are required for the storage of autopsy equipment, as well as for any personal protective equipment morticians or medical examiners may require.

#Trolleys for the conveyance of bodies must be provided in the mortuary and adequate provision for the storage of these units must be available.

#The use of wood, such as for wooden doorframes, is not allowed in wet areas.

#Stainless steel bump rails or plates should be fitted in areas prone to damage from trolleys. These devices shall be fitted such that that they do not affect the integrity and cleanability of the walls and floors. These devices shall not create crevices or gaps which could <s>would</s> harbour pathogens or create a hygiene problem. Welded stainless steel sections shall be stainless steel Grade 316L

 

#VENTILATION

#<s>Mortuaries</s> Mortuary areas require good ventilation. The exhaust air is to be discharged to atmosphere such that it cannot be drawn back into the mortuary, any other ventilation inlet, or any indoor portion of the hospital.

#All external ventilation openings should be fly- and vermin- proof.

#Exhausted air may not pose a hazard to any person who is outside the mortuary. (See room-requirement sheets) Air exhausted from clinical areas should be safely discharged to outside with no chance for re-entrainment or contamination of other indoor spaces. Where these precautions are by no means possible, exhaust air shall be EN1822 H13 HEPA filtered.

#Sufficient ventilation is required for controlling noxious odours present in mortuaries and should also provide a means of protection to personnel working in the facility from possible airborne infections originating from corpses.

#Airborne- infection control is of particular concern and must be designed for in terms of the ventilation system. Tuberculosis, Hepatitis and HIV are <s>of</s> among the most regularly encountered diseases in mortuaries in South Africa and, as such, the spread of these pathogens beyond the mortuary, via a ventilation system, must be avoided by implementing the airborne- contamination control principles for high- risk areas in the ventilation system design. Refer to the '''''IUSS Building Engineering Services''''' guidance document for further guidance on airborne- contamination control principles.

#The ventilation system must be designed such that airborne pathogens that may be present in the body- holding area and autopsy room do not contaminate the remainder of the mortuary facility.

#No recirculation of air extracted from the clinical areas is permitted.

#Air from public areas, with the exception of viewing rooms, may be recirculated where this is in accordance with the National Building Regulations.

#Exhaust ventilation is to be designed in such a manner that this extracts from the areas with the highest risk of infection, while “clean” air is to be supplied into the lower- risk areas. This is to create a pressure cascade with cleaner areas being at a relatively higher air pressure than dirty areas.

#Air- supply registers should be at a high level and the extraction registers should be at a low level. The low- level extraction grilles shall not be more than 500mm above the finished floor level of the room <s>where</s> from which the extraction is taken <s>from</s>. Low- level air- register positions shall consider locations of water points and potential splashing during washing.

 

#AIR CONDITIONING

#The mortuary and autopsy area must have a temperature maintained <s>at</s> between 20˚C <s>to</s> and 21˚C.

#Public areas must be kept at a constant temperature between 23˚C and 25˚C.

#Air extracted from the mortuary may not be used for energy recovery or recirculation.

 

#REFRIGERATION EQUIPMENT DESIGN AND INSTALLATION

#All heat- rejection equipment associated with refrigeration in the body- storage facilities must be located on the outside of the mortuary, in a well-ventilated space at the rear of the fridge(s). Compressors installed on top of body cabinets on the inside of the mortuary are not acceptable. Heat build-up within the mortuary, as a result of this type of arrangement, potentially leads to equipment failure.

#Regularly serviced refrigeration equipment components should not be situated within the confines of the mortuary. Refrigeration technicians should not be required to climb onto or over a body cabinet to carry out any maintenance work. It is preferable to have refrigeration equipment situated in a separate ventilated area to the rear of the body cabinets. The designer is to refer to the selected heat- rejection equipment’s installation manual to determine free space and ventilation openings required around this equipment, since these details can vary between system types.

#Gauges indicating the temperature within the body cabinet must be clearly visible above the door of the unit in order that this can be readily monitored.

#The acceptable average temperature within a normal body cabinet or refrigerated room is between 2.0˚C and 6˚C. In instances where a body has to be kept for an extended period of time a cabinet temperature of at least -20˚C is required.

#In facilities where large quantities of bodies are kept, cold rooms for the storage of multiple bodies on trays are recommended.

#The materials used for the construction of the units are to be of stainless steel to facilitate cleaning and long-term maintenance of the equipment. Grade 316 stainless steel (18/10) is preferable over Grade 304 (18/8), as it offers better corrosion resistance'''.'''

#For welded stainless steel construction, Grade 316L or similar is required.

#If a facility is required to collect and retain forensic samples, refrigeration equipment should be provided for the preservation of these samples. Preferably this equipment should be placed in an area where <s>they</s> it can readily be secured from unauthorised access and tampering.

 

#SECURITY ARRANGEMENTS

#Due to the medical and legal nature of the contents of a mortuary, it is essential that a mortuary has good access control and security systems.

#Theft from mortuaries should be forestalled by, inter alia, constantly monitoring all entrances and preventing free access to mortuary areas. This is especially important for the body- storage areas. Access card or tag systems are open to misuse and are not an appropriate access- control measure. Combinations of tag and biometric access- control systems are recommended.

#Door closers with a “hold-open” mechanism should be installed on the mortuary room doors. This enables doors to close automatically with normal traffic, but can also be held open when moving equipment or trolleys through. “Crash”- type doors should be avoided as these are not easily cleanable and are subject to damage and abuse.

#It is recommended that a timed alarm be fitted to doors to ensure that they are closed shortly after any entrance or exit. This is to <s>mitigate</s> militate against the tendency of keeping doors open with some form of door stopper.

#Body cabinets are to be fitted with locks to prevent the unauthorised opening of these units to forestall the theft of any personal items of the deceased.

#In instances where historical problems relating to unauthorized entry into mortuaries is evident, it is recommended that closed-circuit TV systems be installed to help in monitoring and securing the facility.

PART C – Operation

#OBJECTIVES

The project planning, design, construction and commissioning should aim to provide:

#a safe, secure and functional environment for visitors and staff;

#low capital and ongoing operating costs (service, staffing and maintenance);

#an environmentally appropriate design solution; and

#a fully accessible, inclusive environment.

 

#HEALTH AND SAFETY

In light of the above it is essential that every effort be made to ensure that personnel working in the mortuary are provided with all required personal protective equipment (PPE), as this is essentially an area where pathogens could be present and present a health risk to staff. The following items should be available to staff as a minimum:

#Rubber aprons (or similar impervious material)

#Latex gloves (or similar impervious material)

#Mesh gloves in facilities where post mortems are performed

#Disposable gowns

#Safety glasses or full-face visors.

#Waterproof footwear

#Face masks

#Respirators with the appropriate filters must be available for use in high-risk situations.

#Storage space for PPE

No one should be permitted to enter the body storage and preparation areas without donning appropriate gowns and footwear.

#MAINTENANCE

When designing the facility, every effort must be made to limit the amount of maintenance that would be necessary to keep it in good condition. Seamless surfaces for walls and floors are critical, as this will reduce ongoing maintenance costs. The following minimum requirements should be complied with:

#Seamless floor coverings required

#Radiuses corners ??? required between floors and walls.

#No sharp corners on any work surfaces that could injure people working in the area.

#Ceilings to be readily cleanable.

#Work surfaces are to be impervious to liquids and resistant to staining and corrosion.

#Refer to the room- requirement sheets herein and the IUSS Materials and Finishes guidance documents for further information on the general requirements for materials and finishes.

#All equipment requiring calibration, such as fridges and scales, are to be attended to on an annual basis or when it is suspected that they are defective in respect of their expected/intended performance

PART D – User Room Requirements

Room-requirement sheets

Table 3: Accommodation schedule
{| class="wikitable"
|'''Room Name'''
|'''Service Description'''
 
|'''Area'''

'''(m²)'''
|'''Min. Ceiling Height'''

'''(m)'''
|'''Occupancy'''

'''(Persons)'''
|'''Nominal Utilisation per day'''

'''(hours)'''
|-
|Ablution areas
|Ablution areas – male and female

One WHB per WC or urinal
|3 (per cubicle)
|2.8
|1
|4
|-
|Shower facilities
|Shower facilities – male and female
|3 (per cubicle)
|2.8
|1
|2
|-
|Changing room
|Staff changing room - lockers to be provided
|8
|2.8
|2
|2
|-
|Storage space
|Equipment and PPE storage space
 
|8
|2.8
|1
|1
|-
|Offices
|Office space – interview, body receiving, pathologist
|9
|2.8
|2
|8
|-
|Body/bier room
|Area where a body can be laid out for viewing and identification
|9
|2.8
|1
|8
|-
|Viewing room
|Viewing room – external to body- layout area
|9
|2.8
|4
|1
|-
|Autopsy room
|Autopsy facility – Autopsy table with water supply and discharge and extraction ventilation. WHBs and stainless steel working surfaces
|27
|2.8
|3
|3
|}

'''Table 4: Room services sheet'''
 
{| class="wikitable"
|'''Room Name'''
|'''Temp'''

'''(°C)'''
|'''Ventilation'''

'''(AC/h)'''
|'''Ventilation'''

'''Type'''
|'''Pressure Relative to'''

'''Ambient'''
|'''Wet Services'''
|'''SSO'''

'''400V'''
|'''SSO'''

'''230V'''
|'''Task Illuminance'''

'''(lux)'''
|'''Data Points'''
|'''Colour Rendering'''

'''(Ra)'''
|-
|Reception area
|22-25°C
|2
|Forced supply
|=
|
|0
|0
|100 at floor level
|0
|80
|-
|Visitors ablution areas
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|WC,

WHB
|0
|0
|150 at floor level
|0
|80
|-
|Public waiting area
|22-25°C
|2
|Forced supply
|<nowiki>+ </nowiki>
|
|0
|0
|100 at floor level
|0
|80
|-
|Offices
|22-25°C
|2
|Forced supply/ recirc.
|=
|
|0
|2
|300 at desk level
|1
|80
|-
|Circulation Spaces
|22-25°C
|10
|Forced supply/ recirc.
|=
|
|0
|0
|200 at floor level
|0
|80
|-
|Viewing room
|22-25°C
|2
|Forced supply
|<nowiki>+ </nowiki>
|
|0
|0
|100 at floor level
|0
|80
|-
|Layout room
|20-21°C
|2
|Forced extraction
|<nowiki>- </nowiki>
|WHB
|0
|0
|300 at table level
|1
|80
|-
|Storage space
|22-25°C
|4
|Forced supply
|=
|
|0
|1
|200 at floor level
|0
|80
|-
|Mortuary
|20-21°C
|12
|Forced extraction
|<nowiki>- </nowiki>
|WHB,

FD
|0
|1
|200 at floor level
|0
|80
|-
|Mortuary plant area
|n/a
|n/a
|Natural ventilation
|=
|
|1
|1
|150 at floor level
|0
|80
|-
|Autopsy table
|20-21°C
|20
|Forced extraction
|<nowiki>- </nowiki>
|CW Faucet
|0
|1
|5200 at table level
|0
|90
|-
|Autopsy room
|20-21°C
|20
|Forced extraction
|<nowiki>- </nowiki>
|WHBs,

FD
|0
|2
|500 at floor level
|1
|90
|-
|Changing room
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|WHB
|0
|1
|150 at floor level
|0
|80
|-
|Staff ablution areas
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|WHB,

WC
|0
|0
|150 at floor level
|0
|80
|-
|Shower facilities
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|CW + HW

Faucet
|0
|0
|150 at floor level
|0
|80
|}

'''Table 5: Room finishes'''
 
{| class="wikitable"
|'''Room Name'''
|'''Floor'''

'''Material'''
|'''Wall / Floor Interface'''
|'''Walls'''

'''Finish'''
|'''Ceiling'''

'''Finish'''
|'''Glazing'''

'''Type'''
|'''WHB'''
|'''Doors'''

'''Type'''
|-
|Ablution areas (all)
|Jointless vinyl sheet
|Skirting coved and finished as per floor
|Ceramic wall tiles with epoxy grout
|Washable acrylic paint
|Obscure laminate safety glass
|1 per WC or urinal
|Solid wood with galvanised steel or stainless steel sheet trolley plates
|-
|Public waiting area
|Jointless vinyl sheet
|Coved vinyl skirting
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Lockable glazed entrance door
|-
|Changing room
|Jointless vinyl sheet
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Obscure laminate safety glass
|0
|Solid wood with galvanised steel or stainless steel sheet trolley plates
|-
|Storage space
|Jointless vinyl sheet
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood with galvanised steel or stainless steel sheet cladding
|-
|Offices
|Jointless vinyl sheet
|Coved vinyl skirting
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood
|-
|Body Room
|Self- levelling epoxy
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood
|-
|Viewing Room
|Self- levelling epoxy
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood
|-
|Autopsy Room
|Self- levelling epoxy
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Obscure laminate safety glass
|Min 1 per autopsy table
|Solid wood with galvanised steel or stainless steel sheet cladding
|-
|Circulation Spaces
|Jointless vinyl sheet
|Coved vinyl skirting
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|
|}
'''PART E – Examples and case studies'''

Figure 4 demonstrates the relationships between the zones within the mortuary. In this example it is evident how visitors are managed and kept out of the working portions of the mortuary through segregation in the internal layout. The process flow of the bodies into, through and out of the mortuary has been well considered in that the flow is linear with bodies entering the mortuary <s>on</s>at one end of the facility and exiting at the other. Unfortunately, the restrictions presented by the location of the mortuary, as can be studied in Figure 3, has forced the design into a number of compromises relating to the external flow and access to the mortuary. Staff access is quite severely compromised in being through the mortuary lobby. This mortuary lobby, in the absence of a dedicated preparation room, has the potential of being used as one. This arrangement may impact negatively on the dignity of some staff, the dignity of the deceased, and mortuary security.

Visitors’ access to the mortuary and their adjacent toilets is near the hearse bay and turning areas. There is no natural screening of this entrance from the activities in the hearse bay and it is not inconceivable that visitors may inadvertently wander into the wrong area and be exposed to operational activities not appropriate for the bereaved.

The door sizes of the body storage rooms seem too small for the easy passage of a body trolley when compared to the double doors made available for the passage of the body from there through the remainder of the facility. Door size selection should not be limited by the fact that these are cold room doors. Where doors are too small for free passage of trolleys and porters, <s>their</s> the doors’ service life would be severely shortened and any savings made on the door selection would be lost to maintenance or retrofitting an improved solution.

The access to the technical area for maintenance of the refrigeration equipment in this example meets the recommendations. Here technicians do not need to enter the mortuary to perform the majority of their work and these areas are quite well separated from the admin and visitors’ areas.

 

#EXAMPLE 2: LARGE MORTUARY WITH AUTOPSY FACILITIES

Figure 5 shows the layout of a standardised mortuary design. This is a large facility with autopsy capacity. Figure 6 has been presented in order to promote an understanding of the interrelationship between the various functional parts of the mortuary.

Considering the entrances shown in Figure 5, it is clear that the designer has <s>taken some</s>made an effort to screen the <s>visitor’s</s> visitors’ entrance from the hearses’ entrance. The staff entrance is also well positioned. The staff ablution<s>s</s> facilities and showers are located between the clinical areas and the admin areas. This arrangement encourages good segregation and gowning practice when moving between the mortuary activities and external movement.

The staff and visitors’ access positions are located well away from the working clinical areas of the mortuary and are also relatively remote from each other. This aids in improving security as it discourages the staff and visitors from using the wrong entrances and thereby assists in identifying persons who are present in areas where they do not belong.

This design doesn’t have a dedicated body prep area and it is assumed that the weighing and measuring area is therefore used for this purpose.

The large sliding doors of the cold room in this example can be compared to the cold-room doors in Figure 3 as an indication of what the door size should be like to enable easy passage.

The layout in this example does not provide for a dedicated exit yard and bodies and hearses entering and leaving the facility do so through the same entrance. This arrangement increases the potential for mistakes in body handling.

The common use of the bier room as access to the ID room seems to be a compromise resulting from the limited space provided for these rooms.

'''EXAMPLE 3: LARGE MORTUARY WITH AUTOPSY FACILITIES'''

The example shown in Figure 7<s>Figure 7</s> is a standard facility layout, very similar to that of Figure 5<s>Figure 5</s>, with the most notable changes being the inclusion of a dedicated vehicle- exit yard and the omission of the technical service area. The addition of the exit detail resolves the criticism of the arrangement in Example 2, while the omission of the technical service area for the refrigeration equipment could present an access problem for maintenance technicians, as discussed earlier in this document.

The example in Figure 7<s>Figure 7</s> has also resolved the compromises <s>to</s> in the arrangement of the bier rooms and ID/viewing rooms’ available space, discussed in the previous example.

'''DEFINITIONS'''

In the context of this document the following definitions pertain:
{| class="wikitable"
|'''Autopsy room:''' Synonymous with post–mortem examination area or suite.
|-
|'''Containment facility:''' The part within the demarcated zone in which the most malodorous activities occur. This facility includes the decomposing bodies’ post-mortem examination room, airlock ante room, and a decontamination unit each for men and women. The containment facility is sealed off from the rest of the demarcated area.
|-
|'''Demarcated area:''' The demarcated area, including the post-mortem examination rooms and all supporting functional spaces is the area where most sensitive, costly and specialised processes occur.
|-
|'''Dignity of deceased:''' The principle that bodies are treated with the respect and dignity befitting any person prior to death.
|-
|'''Dissection room or suite:''' Synonymous with post-mortem examination area or suite.
|-
|'''Mortuary:''' A mortuary is a facility for temporary storage of the deceased pending identification, medico-legal investigation and despatch.
|-
|'''Natural death:''' A death <s>by</s>from natural causes which <s>is</s> are determined to have been the cause of illness <s>of</s>or an internal malfunction of the body <s>which was</s> not caused by external forces.
|-
|'''Post-mortem examination area or suite''': A room and its attached service rooms designed for the performing of post-mortem examinations.
|-
|'''Post-mortem examination:''' Examination after death, which may include performance of an autopsy.
|-
|'''Unnatural death:''' A death which is not classified as being a '''''Natural Death'''''
|-
|'''Work bench (or bench):''' Unless otherwise specified, this is a surface ergonomically dimensioned for use from the standing position. This is normally 900mm.
|-
|'''Work-station:''' Unless otherwise specified, this is a surface ergonomically dimensioned for use from the seated position. This is normally 750mm. ??
|}

Page Break

'''BIBLIOGRAPHY'''

To be sorted out and made consistent - as advised to Mr Van Reenen
{| class="wikitable"
|REQUIREMENTS FOR THE FACILITIES AND OPERATION OF MORTUARIES (Second Edition 2009), NPAAC Tier 4 Standard. Australian Government Department of Health and Ageing.
|-
|MANAGING HEALTH AND SAFETY RISKS IN NEW ZEALAND MORTUARIES.(November 2000) Dr Chris Wells and Dr Jeff Brownless
|-
|Mortuary design and hazards. J. clin. Path. (1961), 14, 103
|-
|Health Authority Abu Dhabi. Part B- Version 3.1, June 2011
|-
|Design and layout of Mortuary Complex for a Medical College and Peripheral Hospitals. (2011) BasantLalSirohiwal, Paliwal PK, Luv Sharma and Hitesh Charlwa
|-
|Planning and design of modern mortuary complex in tertiary care. IIJFMT 4(1) 2006. Dr Sanju Singh, Dr U.S. Sinha, Dr A.K. Kapoor, Dr S.K. Verma, Dr Dalbir Singh, Dr Susheel Sharma
|-
|Australian Health Facility guidelines. Revision v.4.0 16-Dec-10
|-
|Mortuary Facilities – Design and improvement guide. CSIR March 2002
|-
|Project development brief for the new academic M6 pathology forensic laboratory. Western Cape Department of Health, August 2009
|-
|National Code of Guidelines for Forensic Pathology Practice in South Africa. Edited by NFPSC Academic Sub-committee 20 August 2007
|-
|IUSS Building Engineering Services guidance document
|}
{{Expand}}
[[Category:Procurement and Operation]]

Maintenance

2022-07-22T09:03:20Z

Tmojanaga: Adding text

Contents

OVERVIEW 5<s>6</s>

'''''Abbreviations''''' 9<s>8</s>

PART A – POLICY AND SERVICE CONTEXT 11<s>9</s>

Legislation, policies and international guidance 11<s>9</s>

1. LEGISLATIVE CONTEXT 11<s>9</s>

2. Further reference material and precedent<s>:</s> 11<s>9</s>

3. INFECTION PREVENTION AND CONTROL LEGISLATION 12<s>10</s>

4. BUILDING LEGISLATION 12<s>10</s>

5. SOUTH AFRICAN BUILDING PRACTICE POLICY AND GUIDELINES 12<s>10</s>

6. INTERNATIONAL DESIGN GUIDANCE 12<s>10</s>

Service Context 13<s>11</s>

PART B – PLANNING AND DESIGN 15<s>12</s>

1. INTRODUCTION 15<s>12</s>

2. LOCATION OF THE MORTUARY AND ACCESS ROUTES 16<s>13</s>

3. FACILITY CAPACITY 16<s>13</s>

4. SELECTING BODY STORAGE SYSTEMS 18<s>14</s>

5. FACILITY LAYOUT 18<s>15</s>

6. MORTUARY EQUIPMENT REQUIREMENTS 21<s>17</s>

7. MOVEMENT WITHIN A MORTUARY 22<s>18</s>

8. SERVICES REQUIRED 24<s>19</s>

9. BIOLOGICAL SAFETY 24<s>19</s>

10. FINISHES TO FLOORS AND WALLS 25<s>20</s>

11. AUTOPSY EQUIPMENT/FIXTURES 26<s>20</s>

12. VENTILATION 27<s>21</s>

13. AIR CONDITIONING 27<s>22</s>

14. REFRIGERATION EQUIPMENT DESIGN AND INSTALLATION 28<s>22</s>

15. SECURITY ARRANGEMENTS 28<s>22</s>

PART C – OPERATION 30<s>24</s>

1. OBJECTIVES 30<s>24</s>

2. HEALTH AND SAFETY 30<s>24</s>

3. MAINTENANCE 30<s>24</s>

PART D –USER ROOM REQUIREMENTS 32<s>32</s>

Room Requirement Sheets 32<s>32</s>

PART E – EXAMPLES AND CASE STUDIES 36<s>35</s>

Layout Examples 36<s>35</s>

1. EXAMPLE 1: SMALL MORTUARY ATTACHED TO HOSPITAL 38<s>36</s>

2. EXAMPLE 2: LARGE MORTUARY WITH AUTOPSY FACILITIES 39<s>37</s>

3. EXAMPLE 3: LARGE MORTUARY WITH AUTOPSY FACILITIES 43<s>40</s>

BIBLIOGRAPHY 46<s>42</s>

'''Table of Figures'''

Figure 1 Adjacency Diagram 1<s>16</s>

Figure 2: Access and Movement in a mortuary 1<s>18</s>

Figure 3 Example 1: Layout 1<s>35</s>

Figure 4 Example 1: Zoning & Access 1<s>36</s>

Figure 5 Example 2: Layout 1<s>38</s>

Figure 6 Example 2: Zoning and Access 1<s>39</s>

Figure 7 Example 3: Layout 1<s>40</s>

'''Table of Tables'''

Table 1 : IUSS Reference documents 8<s>7</s>

Table 2 Service Requirements 13<s>11</s>

Table 3 Accommodation Schedule 32<s>25</s>

TABLE 4 ROOM SERVICES SHEET 33<s>26</s>

TABLE 5 ROOM FINISHES 34<s>27</s>

''Version Control''
{| class="wikitable"
|''Template''
|''January 2013''
|''Tobias van Reenen''
|-
|''Discussion Draft 1''
|''February 2013''
|''Steve Fourie''
|-
|''Discussion Draft 5''
|''March 2013''
|''Steve Fourie''
|-
|''Discussion Draft 6''
|''May 2013''
|''Steve Fourie''
|-
|''Development Draft 1''
|''August 2013''
|''Tobias van Reenen''
|-
|''Development Draft 3.1''
|''February 2014''
|''Tobias van Reenen''
|-
|''Development Draft 3.1''
|''February 2014''
|''Prof J Vellema''
|}

Page Break

OVERVIEW

This document outlines the policy and service context and attempts to illustrate the desired planning principles and design considerations for mortuary services.

*''Part A'' outlines the South African legislation, policies and international guidance reference documents and the service context with respect to mortuary services;
*''Part B'' Planning and design;
*''Part C'' operation;
*''Part D'' user room requirements; and
*''Part E'' provides case studies.

Parts D and E are intended to demonstrate how the principles prescribed in Part A, B, and C can be applied in worked examples. Part D, if used directly, are deemed<s>-</s> to<s>-</s> satisfy the principles developed in Part B, but are not the only acceptable solutions.

Case studies (Part E) provide illustrative worked solutions and should not be adopted without appropriate contextual adaptation.

While this document outlines design requirements and acceptance criteria which have an impact on clinical services, these requirements are prescribed within the framework of the entire IUSS set of guidance documents and cannot be viewed in isolation. The following documents should be complied with, together with this document:

*IUSS: Regulations
*IUSS: Project Planning and Briefing
*IUSS: Environment and Sustainability
*IUSS: Hospital Design Principles
*IUSS: Infection Prevention and Control

Page Break

The following table identifies additional IUSS guideline documents which are recommended for reading in conjunction with this guideline.

'''Table 1 : IUSS Reference documents'''
{| class="wikitable"
|

'''CLINICAL'''

'''SERVICES'''
 
|Essential
|Recommended
|'''SUPPORT'''

'''SERVICES'''
|Essential
|Recommended
|'''HEALTHCARE ENVIRONMENT/ CROSSCUTTING ISSUES'''
|Essential
|Recommended
|'''PROCUREMENT'''

'''& OPERATION'''
|Essential
|Recommended
|-
|Adult Inpatient Services
|
|X
 
|Administration and Related Services
|
|
|Generic Room Requirements
|
|
|Integrated Infrastructure Planning
|
|
|-
|Clinical and Specialised Diagnostic Laboratory Guidelines
|
|X
|General Hospital Support Services
|
|X
|Hospital Design Principles
|
|
|Briefing Manual
|
|X
|-
|Mental Health
|
|
|Catering Services for Hospitals
|
|
|Building Engineering Services
|X
|
|Space Guidelines
|
|
|-
|Adult Critical Care
|
|
|Laundry and Linen Department
|
|X
|Environment and Sustainability
|
|
|Cost Guidelines
|
|
|-
|Emergency Centres
|
|
|Hospital Mortuary Services
|
|
|Materials and Finishes
|X
|
|Procurement
|
|
|-
|Maternity Care Facilities
|
|
|Nursing Education Institutions
|
|
|Future Healthcare Environments
|
|X
|Commissioning Health Facilities
|X
|
|-
|Adult Oncology Facilities
|
|
|Health Facility Residential
|
|
|Healthcare Technology
|
|
|Maintenance
|X
|
|-
|Outpatient Facilities
|
|X
|Central Sterile Service Department
|
|
|Inclusive Environments
|
|
|Decommissioning
|X
|
|-
|Paediatrics and Neonatal Facilities
|
|
|Training and Resource Centre
|
|X
|Infection Preventive Control
|X
|
|Capacity Development
|
|
|-
|Pharmacy
|
|
|Waste Disposal
|
|X
|Health Informatics
|
|
|
|
|
|-
|Primary Health Care Clinics and CHCs
|
|
|
|
|
|Regulations
|
|
|
|
|
|-
|Diagnostic Radiology
|
|
|
|
|
|
|
|
|
|
|
|-
|Adult Physical Rehabilitation
|
|
|
|
|
|
|
|
|
|
|
|-
|Sub-acute services
|
|
|
|
|
|
|
|
|
|
|
|-
|Facilities for Surgical Procedures
|
|
|
|
|
|
|
|
|
|
|
|-
|TB Services
|
|
|
|
|
|
|
|
|
|
|
|}

'''''Abbreviations'''''
{| class="wikitable"
|ACH
|Air changes per hour
|-
|ASHRAE
|American Society of Heating, Refrigerating, and Air-Conditioning Engineers
|-
|BMS
|Building Management System
|-
|BSL
|Biological safety level
|-
|CDC
|Centers for Disease Control (USA)
|-
|CSIR
|Council for Scientific and Industrial Research
|-
|FD
|Floor drain
|-
|FPS
|Forensic Pathology Service
|-
|HVAC
|Heating Ventilation Air Conditioning
|-
|HBA
|Hazardous biological agents
|-
|HCS
|Hazardous chemical substances
|-
|HEPA
|High efficiency particulate air filters
|-
|IPC
|Infection prevention and control
|-
|ISO
|International Standards Organisation
|-
|MDR TB
|Multi-drug resistant TB
|-
|NDoH
|National Department of Health
|-
|NBR
|National Building Regulations
|-
|<s>NDoH</s>
|<s>National Department of Health</s>
|-
|NHS
|National Health Service (UK health service)
|-
|NIOSH
|National Institute of Occupational Safety and Health (US agency)
|-
|O&M
|Operating and Maintenance (manual)
|-
|OHS
|Occupational health and safety
|-
|OQ
|Operational qualification
|-
|PGWCDoH
|Provincial Government Western Cape Department of Health
|-
|PPE
|Personal protective equipment
|-
|PQ
|Performance qualification
|-
|RDS
|Room data sheets
|-
|RH
|Relative humidity
|-
|SABS
|South African Bureau of Standards
|-
|SAO
|Senior Administrative Officer
|-
|SAPS
|South African Police Service
|-
|SI
|<s>Le Systeme International d' Unites</s> Le Système International d’Unités
|-
|SOP
|Standard Operating Procedures
|-
|SS
|Stainless steel
|-
|TB
|Tuberculosis
|-
|WC
|Toilet
|-
|WHB
|Wash-hand basin
|-
|WHO
|World Health Organisation
|-
|XDR TB
|Extreme (or extensively) <s>-</s>drug- resistant TB
|-
|
|
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|}
PART A – Policy and service context

Legislation, policies and international guidance
 

#LEGISLATIVE CONTEXT

The following documents, as amended (though not an exhaustive list) pertain and contain an additional resource of information which would supplement and provide the basis of a design brief. A finer sense of standard operating procedures and legislative context is likely to inform and enhance the design process, so the professional teams are encouraged to use these as an additional resource:
 

*Inquest Act<s>,</s> 58, 1959
*National Health Act<s>,</s> 61, 2003
*Government Notice R363, 2013 [Regulations relating to the management of human remains]
*Government Notice R178, 2012 [Regulations relating to the registration of microbiological laboratories and the acquisition, importation, handling, maintenance and supply of human pathogens]

*Health Professions Amendment Act, 29, 2007
*Criminal Procedures Act<s>,</s> 51, 1977
*Births and Deaths Registration Act<s>,</s> 51, 1992
*National Environmental Management: Waste Act<s>,</s> 59, 2008
*National Archives of South Africa Act<s>,</s> 42, 1996

*Regulations regarding the Rendering of Forensic Pathology Service, ''Government Gazette'' No 30075. No R636, 20 July 2007
*Space Planning Norms and Standards for Office Accommodation used by Organs of State, ''Government Gazette'' No 27985. No 1665, 2 Sept 2005
*Western Cape Health Care Waste Management Draft Bill
*Municipal by<s>-</s>laws, as applicable
*National Code of Guidelines for Forensic Pathology Practice in South Africa, 20 Aug 2007

*Standard Operating Procedures, Forensic Pathology Service, PGWCDoH, 2006
*Biosafety in Microbiological and Biomedical Laboratories, U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention and National Institutes of Health, Fifth Edition, <s>2007</s> US Government Printing Office, Washington: 2007

 

#Further reference material and precedent<s>:</s>

 

*Standard specification for air-conditioning and ventilation systems, Western Cape Department of Public Works, 1998
*Fire security: a guide for architects, Western Cape Department of Public Works, 1998
*Standard electrical specification, South African Department of Public Works, 2005
*Facilities for mortuary and post-mortem room services, NHS Estates, 2001, ISBN 0-11-322000-00
*Part B – Health facility briefing and planning, Australasian Health Facilities Guidelines, 2007

*CKS 336: 2013 Mortuary Trolleys - SABS

#INFECTION PREVENTION AND CONTROL LEGISLATION

The National Infection Prevention and Control Policy and Strategy document makes specific reference to certain Acts and their relevant regulations, which bear relevance to the development and implementation of these health facility guidelines. These are:

*The South African Constitution, 1996 [Sections 2, 24, 27, 36 and 39], as amended
*The Occupational Health and Safety Act of 1993, Act No 85 of 1993 [Section 8(1)]

*Government notice R1390 of 27 December 2001 [Hazardous Biological Agents Regulation] as promulgated under Section 43 of the Occupational Health and Safety Act of 1993
*Government notice R908 of 27 June 2003 [Hazard Analysis Critical Control Point Regulation] as promulgated under Section 15(1) of the Foodstuffs, Cosmetic and Disinfectants Act of 1972
*The Environmental Conservation Act of 1989, Act No 73 of 1989
*The Foodstuffs, Cosmetic and Disinfectants Act of 1972, Act No 45 of 1972

 

#BUILDING LEGISLATION

The following legislation and regulations impact and provide guidance on the provision and design of health care facilities as above:

*The National Environmental Management Act 107 of 1998, as amended
*Building regulations and Building Standards Act 103 of 1977, as amended
*National Building Regulations; SANS 10400:2010, Code of Practice for the Application of the National Building Regulations

*Promotion of Equality and Prevention of Unfair Discrimination Act No 4 of 2000
*General Procedures and Loadings adopted in the Design of Buildings, SABS 0160, 1993
*Structural Use of Concrete Design, SABS 0100-1, 1992
*Structural Use of Concrete – Materials and Execution of Work, SABS 0100-2, 1992
*Specification for Civil Engineering Construction SABS 1200

 

#SOUTH AFRICAN BUILDING PRACTICE POLICY AND GUIDELINES

*R158 of 1980 regulations pertaining to Private Hospitals and Unattached Operating Theatres – R198
*Good Pharmacy Practice, Board Notice 129 of 2004, as amended [see Chapter 1].

#INTERNATIONAL DESIGN GUIDANCE

*ASHRAE Standard 52.2, “Method of Testing General Ventilation Air-Cleaning Devices for Removal Efficiency by Particle Size”, 1992, 1999b
*ASHRAE Standard 62, “Ventilation for Acceptable Indoor Air Quality”, 1989
*ASHRAE. “HVAC Design Manual for Hospitals and Clinics, 2003”, 1989
*CIBSE Applications Manual AM10:1997 “Natural Ventilation in Non-Domestic Buildings”, 1998
*CIBSE Applications Manual AM13:2000 “Mixed Mode Ventilation,” 2000

*ASHRAE Standard 170, “Ventilation of Health Care Facilities”, 2008
*QASA. “Know Your Rights” [Accessibility & the Built Environment]
*Department of Health and Human Services. “Environmental Control for Tuberculosis: Basic Upper-Room Ultraviolet Germicidal Irradiation - Guidelines for Healthcare Settings”, 2009
*WHO. “WHO Policy on TB Infection Control in Health-Care Facilities, Congregate Settings and Households”, 2009

Guidance has also been provided by AIA (USA), NHS (UK), and Australian Health Facility Guidelines on Healthcare Building Design. Additional references can be sourced from www.tb-ipcp.co.za

Service Context

The following table gives an indication of the service requirements for mortuaries within different types of public hospitals.

Table 2: Service Requirements
{| class="wikitable"
|'''Service'''
|'''District'''
|'''Regional'''
|'''Tertiary'''
|'''Central'''
|'''Specialised'''
|-
|Small (beds)
|50-150
|Min 300
|Min 400
|
|
|-
|Medium (beds)
|150-300
|
|
|
|
|-
|Large (beds)
|300-600
|Max 800
|Max 800
|Max 1200
|Max 600
|-
|Training
|Where practical
|Where practical
|Optional
|Yes. Attached to medical school
|
|-
|Conduct research
|
|
|
|Yes
|
|-
|'''Mortuary'''
|
|
|
|
|
|-
|Short-term stay (2˚C)
|Yes
|Yes
|Yes
|Yes
|
|-
|Long-term stay (-15˚C)
|Yes
|Yes
|Yes
|Yes
|
|-
|Autopsies (20°C -21°C)
|Yes
|Yes
|Yes
|Yes
|Yes
|}

For the determination of capacity requirements of mortuaries refer to the recommendations further on in this document.

This guidance document relates to mortuaries located within and serving hospitals, with respect to persons that die due to natural causes in that hospital. This document excludes mortuaries <s>exclusively</s> dealing exclusively with cases that require medico-legal investigation of deaths from unnatural causes.

Post mortems conducted in hospital mortuaries should be limited to conducting investigations and procedures where no medico-legal investigation is required and death from natural causes is suspected.

Hospital deaths from natural causes and those suspected to be of unnatural cases should not be managed in the same facility unless the hospital mortuary is equipped to comply with the specific legal requirements as <s>it</s> they relate<s>s</s> to the chain of evidence, etc. The requirements for forensic- pathology service mortuaries are not exhaustively detailed in this document.

It is also noted that some hospitals may opt to contract out the removal and storage of decedents to private undertakers and these hospitals may <s>only</s> require only the minimum in terms of refrigerated body storage.

PART B – Planning and Design

#INTRODUCTION

#All state- run mortuary facilities fall within the domain of the Department of Health, both National and Provincial;<s>,</s> and in an effort to provide engineers and architects who are required to either design new facilities or upgrade existing facilities, this document provides the minimum standards necessary to comply with existing legislation.

#This document will provide designers of this type of facility with guidelines as to what is required in terms of the following:

*Type of service and package of care being provided
*Mortality rate
*Access and egress
*Discreet management of human remains

*Size and dimensions of the actual facility
*Positioning of mortuaries within hospitals
*Finishes of surfaces in these facilities
*Water- supply requirements
*Drainage requirements

*Electrical supply and lighting requirements
*Installation requirements for equipment and services
*Body-storage requirements
*Body-handling facilities
*Body-holding areas

*Body-viewing area
*Autopsy equipment (tables)
*Air conditioning and ventilation requirements (for infection and indoor air quality control)
*Security of the facility

#In addition to the items listed above, it is also necessary to consider the needs of visitors to these facilities, particularly those wishing to, or who are required to, identify bodies. In line with this it is also necessary to take the handling of bodies into consideration as it pertains to issues of patient dignity.

#Forensic pathology mortuaries are not <s>considered</s> exhaustively described in this document, although the majority of mortuaries do have basic facilities for general autopsies that are not necessarily medico-legal in nature. A forensic pathology mortuary has laboratory facilities attached that are outside the scope of regular mortuaries found in hospitals and at police stations. It should be noted that there are a number of principles that hold true for both hospital and forensic pathology mortuaries.

#Compliance with the requirements of the Occupational Health and Safety Act (Act 85 of 1993 as amended) are to be complied with at all times during the design of a mortuary.

 

#LOCATION OF THE MORTUARY AND ACCESS ROUTES

#The position of the mortuary in a hospital should be such that the mortuary is easily accessible to mortuary staff and related service providers without presenting either aesthetic, emotional or ethical problems for unrelated hospital staff, patients or visitors. Visitors to the mortuary, however, should be provided with clear and direct access to the mortuary upon arrival at the hospital, without having to travel unnecessarily through hospital departments.

#Where bodies are moved into or out of the mortuary, they should not be moved through general public-access areas. Appropriate routes would include technical service or goods corridors and through the hospital’s support services yard.

#Special considerations should be given to plans for contingency access to the mortuary in the event of case- load surges, which may <s>be</s> result from disasters.

#Bodies should not be held for any period in any locations between the body- holding rooms within clinical areas and the mortuary.

#Where a mortuary unit is used jointly between the hospital and the local authority it is beneficial for the mortuary to be in a building separate from the main hospital building.

#The delivery of bodies to the mortuary and their subsequent removal from the facility is to be such that it is carried out in a manner that is not visible to the general public, preferably in a covered and enclosed area.

#While siting and access are important aspects when locating a mortuary, it is also important to provide the mortuary with pleasant surroundings in order to promote the dignity of those working in or visiting the mortuary.

 

#FACILITY CAPACITY

#The layout and size of a mortuary is largely determined by the number of bodies stored and whether body storage needs to be in cabinets or in refrigerated rooms.

#In order to determine the storage capacity of a hospital mortuary it is recommended that historical data, where available, should be used. In the South African context it is suggested that a storage capacity of between 5 and 10 bodies per 100 beds should be used. This varies with the rural or urban location of the facility. This capacity should not take into account the need to store bodies from deaths which are not hospital related, typically motor-vehicle accident deaths and deaths from criminal activity. Requirements for contingency storage capacity related to disaster management should be considered.

#The body storage capacity required can be estimated on the basis of the number of deaths per year in the hospital, the length of time of holding and the required body store occupancy rate. The number of body trays can be calculated from Equation 1<s>Equation 1</s> below.

-Equation 1

Where:

BT = Number of body trays

D = Number of deaths per year requiring body trays

S = Average length of stay (in days)

R = Required body tray occupancy rate

[Text Box]

#The estimated storage capacity for bodies in a mortuary could be confounded by a number of local factors, such as:

*Mortality rate from natural causes.
*Mortality rate from infectious disease. (Highly contagious disease deaths require special storage facilities.)

#Where the hospital is expected to place the body in cold storage until collection by forensic pathology services the following additional factors should be considered:

*Mortality rate from foul play.
*Mortality rate from traffic incidents.

 

#SELECTING BODY-STORAGE SYSTEMS

#Body-storage systems are principally divided into refrigerated rooms or body cabinets. Differences within these system types occur where specific temperatures or sizes are required based on risk, need and capacity requirements.

#Where a system of functionally separate body cabinets is selected, this system would have an inherent redundancy against failure, as the failure of a single unit would not necessarily imply a system failure. In contrast, a refrigerated room would require less maintenance and would have a lower frequency of failure; however a single component failure could be critical if standby condensing units are not installed. For this reason, multiple- cabinet systems are recommended for areas where expected maintenance response times would negatively affect the mortuary’s operations.

#It is possible to have a requirement for a mixture of refrigerated rooms and body cabinets. This could be affected by local cultural requirements such as for families <s>which</s> who object to bodies sharing storage space, the case load of the facility or the case profile.

#Where there is a requirement for the long-term storage of bodies, these are to be kept at a lower temperature than would be the case in a refrigerated room. In this instance separate body cabinets are required. Long- term storage of bodies is most often required when an indigent person dies and difficulty is experienced in locating the next of kin, as the person cannot legally be buried until this process has been completed.

#In general, smaller facilities rely on body cabinets for the storage as these facilities do not have the space or the need for the large-scale storage of bodies, <s>and they do not</s>they would not appreciate the functional flexibility offered by these systems. By rule of thumb, any facility that has the requirement to store <s>less</s> fewer than 12 bodies at any given time should use body cabinets. This <s>provides</s> gives the option of providing both short- and long-term storage with the smallest facility and equipment footprint.

#Bodies suspected of having succumbed to a highly contagious and dangerous disease require special treatment. These should be stored in such a manner that they do not present a hazard to personnel working in the mortuary. Typically these bodies should be stored at the same temperature<s>s</s> <s>the same</s> as <s>for</s> long- stay bodies, e.g. -15˚C, and should be placed in hermetically sealed plastic body-bags.

#Provision for the secure cold storage of body parts should <s>also</s> be provided.

 

#FACILITY LAYOUT

#As mentioned, the layout and size of a mortuary is going to be largely determined by case load and whether storage is in cabinets or refrigerated rooms. It is acceptable to have a mixture of refrigerated rooms and body cabinets.

#In a mortuary facility there are a number of separate areas that need to be considered other than the body- storage areas. These include:

#'''Reception area''' for members of the public who are required to visit the mortuary on official business – typically to identify bodies or to pay their last respects to a deceased person.

#'''Ablution areas''' for staff. Where unisex ablutions are provided it is recommended that <s>the</s> no urinal is provided.

#<s>'''Visitor’s'''</s> '''Visitors’ admin space''' close to the reception area, where any admin or official business related to the identifying of a body can be completed.

#'''Staff admin space''' close to the point where a body is delivered to the mortuary, so that pertinent documentation can be completed – both with respect to the delivery of the body, as well as when the body is released from the mortuary again.

#'''Office space''' for pathologists to write up reports <s>for</s> in instances where this could be required. This is dependent on the size of the mortuary as small facilities would not require a separate room(s) for this function.

#'''Waiting''' and circulation areas for visitors to the mortuary.

#'''Viewing room,''' from where a body can be viewed through a curtained glass window between this space and the body- display room.

#'''Body- display''' room, where a body is placed for identification purposes. There is to be access to this area via a lockable door to the viewing room <s>for</s> in instances where it is necessary for non-mortuary personnel to have direct access to a body in the viewing room. There is to be access to this room from the body- storage area to allow bodies to be brought in for display purposes.

#'''Body preparation''' area, where a body that is delivered to the mortuary needs to be attended to prior to it being placed in the viewing room.

#'''Shower facilities''' (staff)

#'''Changing room''' (staff)

#'''Storage space''' for equipment and clothing that is worn in the body-preparation and autopsy spaces.

#'''Body-storage''' facility (cold room or refrigerated cabinets), depending on the length of time that bodies are expected to be kept in the facility.

#'''Autopsy facility,''' where the cause of death can be determined. This facility will differ from mortuary to mortuary, depending on whether forensic or standard medical autopsies to determine the cause of death are conducted.

[GroupDrawing]
 

#Figure 1<s>Figure 1</s> is an example of an adjacency diagram for a typical mortuary. In this instance the proximity also relates to visual and physical access. It is also understood that not all mortuaries would require all of the spaces indicated in this diagram, and that some of the spaces shown as being '''''immediately adjacent''''' could be included as a single area if functionality and privacy considerations permit it.

#There remains abundant scope for variations in the planning of the layouts making up the mortuary. and the hospital architect should consult with all stakeholders to arrive at an ideal solution.

#When developing the facility layout, careful consideration should be given to the routes through the facility of staff, bodies and visitors. These routes should overlap as little as possible and there should never be a common entrance for bodies and staff or visitors.

#The room requirement sheets are presented in ''PART D – User Room Requirements<s>PART D –User Room Requirements</s>''of this document.

#Storage space for body lifts must be provided.

#Suitable sluicing facilities are required to be able to clean equipment and fabrics after completion of any work in the mortuary facility.

 

#MORTUARY EQUIPMENT REQUIREMENTS

#Equipment for storage and transportation of bodies should meet environmental hygiene standards.

#For mortuary trolley design and supply, the SABS published standard '''''CKS336:2013 Mortuary Trolleys''''' is recommended. It should be noted that this is not a normative South African National Standard, and individual requirements may differ.

#'''Body-cabinet''' selection and installation requires the following considerations:

#Three-level body cabinets could be selected which have a single door to give access to all of the body trays, for instances where separation between bodies is required. Alternatively, cabinets that provide a single door for access to all the body trays are acceptable.

#It is critical that bariatric (obese) bodies are catered for in each cabinet. The lowest-level tray should be designed for this purpose.

#Special consideration is to be given to the provision of capacity for storage of juvenile and infant decedents. The handling of these bodies is an especially sensitive and emotive issue, and separate storage in dedicated cabinets is recommended.

#Body lifts must be supplied to facilitate the loading of bodies into and removal of bodies from the cabinets. Body lifts help to preserve dignity when handling bodies, while at the same time making it easier and safer for mortuary personnel to handle bodies.

#A clear space must be provided in front of the body cabinets to allow for the placing of a corpse into the cabinets. It is recommended that there be at least a 3m clearance between the front of the cabinet and any fixed structure. This is to accommodate whatever means of conveyance is used to transport a corpse to ?? and then load it into the cabinet.

#Due to the vast array of cabinets available on the market and the lack of an appropriate national standard, it is not yet possible to prescribe sizes for refrigerated cabinets in this guide.

#The required cabinet size is fundamental when designing a mortuary. Where space is not too limited and there are no indications that there may be cultural concerns relating to the storage of bodies together in a cold room, it is recommended that cold rooms be used. Cold rooms offer space savings when compared to cabinets.

#A temperature gauge must be installed close to the door of the facility to indicate the storage-space temperature. This gauge should have an alarm system connected to it to give a warning should there be an unacceptable rise in temperature in the storage space. Typically, if the temperature should rise more than 2˚C above the set temperature, an alarm should be activated at a point that is manned at all times.

#Body cabinets and refrigerated rooms must be supplied with electrical power from the hospital’s essential services electrical supply.

#A slop hopper is to be provided to allow for the cleaning of the body preparation and autopsy areas, in particular after the completion of any work carried out in these areas.

#To allow for the rinsing of body parts and organs, during an autopsy procedure it is important that suitable basins be provided in close proximity to <s>the</s>a downdraft autopsy table.

#Where there is transition between “clean” and “dirty” areas, provision is to be made to allow for the cleaning of footwear in a “transitional” area. This helps prevent the transport of contaminants from dirty areas.

 

#MOVEMENT WITHIN A MORTUARY

#Movement of members of the public visiting the mortuary is to be restricted such that they do not have access to the body- preparation or autopsy areas. (Figure 2<s>Figure 2</s>)

#The facility must be available within the mortuary where body identification can be conducted in a private and dignified manner. This viewing area should consist of a body- display or layout room with an adjacent viewing room, where the body can be viewed through a curtained shatter-proof glass window.

#The requirement for a viewing and identification area also pertains to hospitals which outsource their mortuary services.

#The viewing room and visitors’ admin rooms should be designed such that counselling can be conducted in a pleasant environment for bereaved persons.

#The design of the viewing facility should allow <s>for</s> adequate space for persons to view a body in a dignified manner.

#Direct access to the body- layout room from the viewing room is to be provided via a lockable door, to allow visitors access to the body.

#Ablution facilities are to be available to members of the public who are required to visit the mortuary complex.

#[GroupDrawing]Where a dedicated room, as described above, cannot be allocated for placing a body for viewing purposes, the persons who are viewing a body should be given a private space for viewing the body through a curtained shatter-proof glass window, as a minimum.

#Adequate facilities to accommodate at least 7 visitors are to be provided.

#Staff access to the mortuary facility is to be separate from the general public. (Figure 2)

#Mortuary staff change rooms should be provided with secure lockers for storage of street garments, lab coats, personal protective equipment and valuables. <s>Street garments and lab garments</s>

#Mortuary staff may have completely separate ablution facilities from those used by the general public requiring access to the mortuary facility.

#In a free- standing mortuary building the delivery to and removal of bodies from the facility may be via the same access point to the building.

#A mortuary that forms an integral part of a hospital will require separate routes for receiving bodies and the subsequent removal thereof.

#In the unusual event that a body arrives from outside <s>of</s> the hospital, the normal route of removal should be used for receipt of the body.

#A clear distinction is to be made between “clean”,” “dirty” / “wet” and “transitional” areas. This is best achieved by creating a physical “RED LINE” on the floor indicating the separation of these areas, with “yellow lines” used to demarcate “transitional” areas. Receptacles for the collections of dirty clothing, etc, must be made available at the transition area from <s>a</s> dirty to clean areas and in change rooms.

#A well-drained facility for washing <s>of</s> vehicles which have been contaminated with decomposed bodies or <s>bodily</s> body fluids should be provided in an enclosed area, near to the mortuary.

 

#SERVICES REQUIRED

#Hygienic floor drains that are resistant to corrosion from blood and chlorine should be provided in all “wet areas” of the mortuary and should be directly connected to the sewer system. These areas include body preparation, autopsy space, etc. These areas require thorough cleaning after every procedure, using large quantities of water and decontaminating and disinfecting chemicals and soaps.<s>.</s>

#Sluicing facilities are to be provided in both the body- preparation and autopsy areas if they are not a common area.

#Open floor channels should be avoided. Where this is not possible, these should be covered by durable, flush- fitted stainless steel grids.

#No sewer connections external to the mortuary services should be made to the line between the wet area drains and the main sewer system in order to prevent backflow to other areas.

#The provision of hot and cold water in the facility is imperative, with all basins, sinks, ablution areas and autopsy tables being provided with both.

#Anti-backflow devices should be fitted to the water- supply lines serving mortuary table faucets to prevent backflow should supply water pressure fail.

#Electricity supply to the mortuary – particularly for refrigeration purposes – is to be provided from the essential supply system for the hospital. Alternatively, a back-up generator is to be supplied to allow for the maintenance of required temperatures in the cooling/freezing facilities in the mortuary.

 

#BIOLOGICAL SAFETY

#A Biosafety Laboratory Level 3 (BSL3) designation (R178-2012) is applicable for any decomposing bodies post-mortem area. This area is identified as a level-3 containment facility.

#BSL3 areas shall have restricted access and shall be separated from regular traffic flow routes.

#All doors opening into the BSL3 areas shall be appropriately labelled with biological safety hazard signage.

#Access to the BSL3 areas shall be through dedicated ventilated airlocks. A pressure differential of minimum +15Pa shall be maintained for the airlock relative to the BSL3 area. This pressure differential is relevant for when the doors are closed only. Room pressure differential gauges are to be fitted at the entrance to the BSL3 area.

#Airlock doors shall be interlocked such that only one door can be opened at a time, thereby preventing direct passage between the corridor and the BSL3 area.

#It is recommended <s>to create</s>that a transfer hatch be created for the transfer of goods between areas with differing biosafety-level classifications. This device shall be designed to preserve the integrity of the containment system and the mechanical ventilation design.

#Air exhausted from biosafety areas should be safely discharged to the outside with no chance for re-entrainment or contamination of other indoor spaces. Exhausts from biosafety areas should be vented at 3m above the roof level. Where such measures are not possible, exhaust air shall be EN1822 H13 HEPA filtered. Exhausts from biosafety areas should include anti-backflow devices.

 

#FINISHES TO FLOORS AND WALLS

#Walls and floor coverings within a mortuary should be easily cleanable and impervious to liquids and staining.

#Floors are to be of such a nature that they are not easily damaged by wheeled items that are moved over them. Vinyl floor coverings are not considered to be resilient enough for this purpose.

#Epoxy floor coverings are preferable, as these are easily maintained and do not have joints in them where liquids can accumulate to become a health risk.

#Corners between walls and floors shall be coved to facilitate the cleaning of these areas. These coving details should be solid and continuous without hidden formwork and cavities.

#Walls are to be coated with hard- wearing and washable materials/paint with provision made for trolley “bumpers” along walls exposed to high traffic. Wall coatings shall be impervious to damage from trolleys and mobile equipment.

#Materials such as vinyl sheeting should not be used to cover walls in wet areas. The risk of growth between the sheeting and the wall presents a health hazard to personnel working in the mortuary wet areas.

#Due to the potential presence of water on flooring it is essential that flooring be non-slip.

#Refer to the room requirement sheets herein and the '''''IUSS Materials and Finishes''''' guidance documents for further information.

#Surface- mounted services should be avoided to ensure smooth and washable surfaces. Where surface mounting of piping is unavoidable, this piping should be mounted on batons, such that the space behind the piping is readily accessible for cleaning.

 

#AUTOPSY EQUIPMENT/FIXTURES

#Equipment for the storage and transportation of bodies should meet environmental hygiene standards.

#In the majority of instances a<s>n</s> downdraft autopsy table is required within a hospital mortuary facility. This table should be one that is designed in such a way that there is a hot and cold water supply that is integral to table installation, as well as a drainage system that can automatically drain water/waste from the table to the sewer system of the facility.

#The autopsy table should have an integrated ventilation extraction or “downdraft” system in order to entrain noxious odours and infectious material that may emanate from a body. This can function to minimise the spread of any airborne pathogens from the body.

#Adequate stainless steel washing basins (at least one per autopsy table) must be provided in close proximity to the autopsy table for the use of personnel working in the facility.

#Electrical power must be provided from a 5 amp IPX5 waterproof single-socket outlet near the autopsy table to allow for the safe use of any electrical equipment that may be required during an autopsy.

#Lighting quality over the autopsy table must be exceptionally good. Refer to the lighting requirements specified in the room- requirement sheets herein and the '''''IUSS Building Engineering Services''''' guidance document for specifications.

#Adequately sized worktops must be provided along the walls of the autopsy area for equipment and specimens prior to storage.

#It is recommended that working surfaces of at least 500x2500mm be provided per autopsy table.

#A balance table for a bench-top scale is required. The scale can be either permanently mounted on the work surface or stored in the autopsy equipment store.

#A platform scale for measuring the weight of an entire body prior to any possible dissection/autopsy work being conducted is to be accommodated.

#Lockable <s>C</s>cabinets are required for the storage of autopsy equipment, as well as for any personal protective equipment morticians or medical examiners may require.

#Trolleys for the conveyance of bodies must be provided in the mortuary and adequate provision for the storage of these units must be available.

#The use of wood, such as for wooden doorframes, is not allowed in wet areas.

#Stainless steel bump rails or plates should be fitted in areas prone to damage from trolleys. These devices shall be fitted such that that they do not affect the integrity and cleanability of the walls and floors. These devices shall not create crevices or gaps which could <s>would</s> harbour pathogens or create a hygiene problem. Welded stainless steel sections shall be stainless steel Grade 316L

 

#VENTILATION

#<s>Mortuaries</s> Mortuary areas require good ventilation. The exhaust air is to be discharged to atmosphere such that it cannot be drawn back into the mortuary, any other ventilation inlet, or any indoor portion of the hospital.

#All external ventilation openings should be fly- and vermin- proof.

#Exhausted air may not pose a hazard to any person who is outside the mortuary. (See room-requirement sheets) Air exhausted from clinical areas should be safely discharged to outside with no chance for re-entrainment or contamination of other indoor spaces. Where these precautions are by no means possible, exhaust air shall be EN1822 H13 HEPA filtered.

#Sufficient ventilation is required for controlling noxious odours present in mortuaries and should also provide a means of protection to personnel working in the facility from possible airborne infections originating from corpses.

#Airborne- infection control is of particular concern and must be designed for in terms of the ventilation system. Tuberculosis, Hepatitis and HIV are <s>of</s> among the most regularly encountered diseases in mortuaries in South Africa and, as such, the spread of these pathogens beyond the mortuary, via a ventilation system, must be avoided by implementing the airborne- contamination control principles for high- risk areas in the ventilation system design. Refer to the '''''IUSS Building Engineering Services''''' guidance document for further guidance on airborne- contamination control principles.

#The ventilation system must be designed such that airborne pathogens that may be present in the body- holding area and autopsy room do not contaminate the remainder of the mortuary facility.

#No recirculation of air extracted from the clinical areas is permitted.

#Air from public areas, with the exception of viewing rooms, may be recirculated where this is in accordance with the National Building Regulations.

#Exhaust ventilation is to be designed in such a manner that this extracts from the areas with the highest risk of infection, while “clean” air is to be supplied into the lower- risk areas. This is to create a pressure cascade with cleaner areas being at a relatively higher air pressure than dirty areas.

#Air- supply registers should be at a high level and the extraction registers should be at a low level. The low- level extraction grilles shall not be more than 500mm above the finished floor level of the room <s>where</s> from which the extraction is taken <s>from</s>. Low- level air- register positions shall consider locations of water points and potential splashing during washing.

 

#AIR CONDITIONING

#The mortuary and autopsy area must have a temperature maintained <s>at</s> between 20˚C <s>to</s> and 21˚C.

#Public areas must be kept at a constant temperature between 23˚C and 25˚C.

#Air extracted from the mortuary may not be used for energy recovery or recirculation.

 

#REFRIGERATION EQUIPMENT DESIGN AND INSTALLATION

#All heat- rejection equipment associated with refrigeration in the body- storage facilities must be located on the outside of the mortuary, in a well-ventilated space at the rear of the fridge(s). Compressors installed on top of body cabinets on the inside of the mortuary are not acceptable. Heat build-up within the mortuary, as a result of this type of arrangement, potentially leads to equipment failure.

#Regularly serviced refrigeration equipment components should not be situated within the confines of the mortuary. Refrigeration technicians should not be required to climb onto or over a body cabinet to carry out any maintenance work. It is preferable to have refrigeration equipment situated in a separate ventilated area to the rear of the body cabinets. The designer is to refer to the selected heat- rejection equipment’s installation manual to determine free space and ventilation openings required around this equipment, since these details can vary between system types.

#Gauges indicating the temperature within the body cabinet must be clearly visible above the door of the unit in order that this can be readily monitored.

#The acceptable average temperature within a normal body cabinet or refrigerated room is between 2.0˚C and 6˚C. In instances where a body has to be kept for an extended period of time a cabinet temperature of at least -20˚C is required.

#In facilities where large quantities of bodies are kept, cold rooms for the storage of multiple bodies on trays are recommended.

#The materials used for the construction of the units are to be of stainless steel to facilitate cleaning and long-term maintenance of the equipment. Grade 316 stainless steel (18/10) is preferable over Grade 304 (18/8), as it offers better corrosion resistance'''.'''

#For welded stainless steel construction, Grade 316L or similar is required.

#If a facility is required to collect and retain forensic samples, refrigeration equipment should be provided for the preservation of these samples. Preferably this equipment should be placed in an area where <s>they</s> it can readily be secured from unauthorised access and tampering.

 

#SECURITY ARRANGEMENTS

#Due to the medical and legal nature of the contents of a mortuary, it is essential that a mortuary has good access control and security systems.

#Theft from mortuaries should be forestalled by, inter alia, constantly monitoring all entrances and preventing free access to mortuary areas. This is especially important for the body- storage areas. Access card or tag systems are open to misuse and are not an appropriate access- control measure. Combinations of tag and biometric access- control systems are recommended.

#Door closers with a “hold-open” mechanism should be installed on the mortuary room doors. This enables doors to close automatically with normal traffic, but can also be held open when moving equipment or trolleys through. “Crash”- type doors should be avoided as these are not easily cleanable and are subject to damage and abuse.

#It is recommended that a timed alarm be fitted to doors to ensure that they are closed shortly after any entrance or exit. This is to <s>mitigate</s> militate against the tendency of keeping doors open with some form of door stopper.

#Body cabinets are to be fitted with locks to prevent the unauthorised opening of these units to forestall the theft of any personal items of the deceased.

#In instances where historical problems relating to unauthorized entry into mortuaries is evident, it is recommended that closed-circuit TV systems be installed to help in monitoring and securing the facility.

PART C – Operation

#OBJECTIVES

The project planning, design, construction and commissioning should aim to provide:

#a safe, secure and functional environment for visitors and staff;

#low capital and ongoing operating costs (service, staffing and maintenance);

#an environmentally appropriate design solution; and

#a fully accessible, inclusive environment.

 

#HEALTH AND SAFETY

In light of the above it is essential that every effort be made to ensure that personnel working in the mortuary are provided with all required personal protective equipment (PPE), as this is essentially an area where pathogens could be present and present a health risk to staff. The following items should be available to staff as a minimum:

#Rubber aprons (or similar impervious material)

#Latex gloves (or similar impervious material)

#Mesh gloves in facilities where post mortems are performed

#Disposable gowns

#Safety glasses or full-face visors.

#Waterproof footwear

#Face masks

#Respirators with the appropriate filters must be available for use in high-risk situations.

#Storage space for PPE

No one should be permitted to enter the body storage and preparation areas without donning appropriate gowns and footwear.

#MAINTENANCE

When designing the facility, every effort must be made to limit the amount of maintenance that would be necessary to keep it in good condition. Seamless surfaces for walls and floors are critical, as this will reduce ongoing maintenance costs. The following minimum requirements should be complied with:

#Seamless floor coverings required

#Radiuses corners ??? required between floors and walls.

#No sharp corners on any work surfaces that could injure people working in the area.

#Ceilings to be readily cleanable.

#Work surfaces are to be impervious to liquids and resistant to staining and corrosion.

#Refer to the room- requirement sheets herein and the IUSS Materials and Finishes guidance documents for further information on the general requirements for materials and finishes.

#All equipment requiring calibration, such as fridges and scales, are to be attended to on an annual basis or when it is suspected that they are defective in respect of their expected/intended performance

PART D – User Room Requirements

Room-requirement sheets

Table 3: Accommodation schedule
{| class="wikitable"
|'''Room Name'''
|'''Service Description'''
 
|'''Area'''

'''(m²)'''
|'''Min. Ceiling Height'''

'''(m)'''
|'''Occupancy'''

'''(Persons)'''
|'''Nominal Utilisation per day'''

'''(hours)'''
|-
|Ablution areas
|Ablution areas – male and female

One WHB per WC or urinal
|3 (per cubicle)
|2.8
|1
|4
|-
|Shower facilities
|Shower facilities – male and female
|3 (per cubicle)
|2.8
|1
|2
|-
|Changing room
|Staff changing room - lockers to be provided
|8
|2.8
|2
|2
|-
|Storage space
|Equipment and PPE storage space
 
|8
|2.8
|1
|1
|-
|Offices
|Office space – interview, body receiving, pathologist
|9
|2.8
|2
|8
|-
|Body/bier room
|Area where a body can be laid out for viewing and identification
|9
|2.8
|1
|8
|-
|Viewing room
|Viewing room – external to body- layout area
|9
|2.8
|4
|1
|-
|Autopsy room
|Autopsy facility – Autopsy table with water supply and discharge and extraction ventilation. WHBs and stainless steel working surfaces
|27
|2.8
|3
|3
|}

'''Table 4: Room services sheet'''
 
{| class="wikitable"
|'''Room Name'''
|'''Temp'''

'''(°C)'''
|'''Ventilation'''

'''(AC/h)'''
|'''Ventilation'''

'''Type'''
|'''Pressure Relative to'''

'''Ambient'''
|'''Wet Services'''
|'''SSO'''

'''400V'''
|'''SSO'''

'''230V'''
|'''Task Illuminance'''

'''(lux)'''
|'''Data Points'''
|'''Colour Rendering'''

'''(Ra)'''
|-
|Reception area
|22-25°C
|2
|Forced supply
|=
|
|0
|0
|100 at floor level
|0
|80
|-
|Visitors ablution areas
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|WC,

WHB
|0
|0
|150 at floor level
|0
|80
|-
|Public waiting area
|22-25°C
|2
|Forced supply
|<nowiki>+ </nowiki>
|
|0
|0
|100 at floor level
|0
|80
|-
|Offices
|22-25°C
|2
|Forced supply/ recirc.
|=
|
|0
|2
|300 at desk level
|1
|80
|-
|Circulation Spaces
|22-25°C
|10
|Forced supply/ recirc.
|=
|
|0
|0
|200 at floor level
|0
|80
|-
|Viewing room
|22-25°C
|2
|Forced supply
|<nowiki>+ </nowiki>
|
|0
|0
|100 at floor level
|0
|80
|-
|Layout room
|20-21°C
|2
|Forced extraction
|<nowiki>- </nowiki>
|WHB
|0
|0
|300 at table level
|1
|80
|-
|Storage space
|22-25°C
|4
|Forced supply
|=
|
|0
|1
|200 at floor level
|0
|80
|-
|Mortuary
|20-21°C
|12
|Forced extraction
|<nowiki>- </nowiki>
|WHB,

FD
|0
|1
|200 at floor level
|0
|80
|-
|Mortuary plant area
|n/a
|n/a
|Natural ventilation
|=
|
|1
|1
|150 at floor level
|0
|80
|-
|Autopsy table
|20-21°C
|20
|Forced extraction
|<nowiki>- </nowiki>
|CW Faucet
|0
|1
|5200 at table level
|0
|90
|-
|Autopsy room
|20-21°C
|20
|Forced extraction
|<nowiki>- </nowiki>
|WHBs,

FD
|0
|2
|500 at floor level
|1
|90
|-
|Changing room
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|WHB
|0
|1
|150 at floor level
|0
|80
|-
|Staff ablution areas
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|WHB,

WC
|0
|0
|150 at floor level
|0
|80
|-
|Shower facilities
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|CW + HW

Faucet
|0
|0
|150 at floor level
|0
|80
|}

'''Table 5: Room finishes'''
 
{| class="wikitable"
|'''Room Name'''
|'''Floor'''

'''Material'''
|'''Wall / Floor Interface'''
|'''Walls'''

'''Finish'''
|'''Ceiling'''

'''Finish'''
|'''Glazing'''

'''Type'''
|'''WHB'''
|'''Doors'''

'''Type'''
|-
|Ablution areas (all)
|Jointless vinyl sheet
|Skirting coved and finished as per floor
|Ceramic wall tiles with epoxy grout
|Washable acrylic paint
|Obscure laminate safety glass
|1 per WC or urinal
|Solid wood with galvanised steel or stainless steel sheet trolley plates
|-
|Public waiting area
|Jointless vinyl sheet
|Coved vinyl skirting
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Lockable glazed entrance door
|-
|Changing room
|Jointless vinyl sheet
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Obscure laminate safety glass
|0
|Solid wood with galvanised steel or stainless steel sheet trolley plates
|-
|Storage space
|Jointless vinyl sheet
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood with galvanised steel or stainless steel sheet cladding
|-
|Offices
|Jointless vinyl sheet
|Coved vinyl skirting
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood
|-
|Body Room
|Self- levelling epoxy
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood
|-
|Viewing Room
|Self- levelling epoxy
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood
|-
|Autopsy Room
|Self- levelling epoxy
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Obscure laminate safety glass
|Min 1 per autopsy table
|Solid wood with galvanised steel or stainless steel sheet cladding
|-
|Circulation Spaces
|Jointless vinyl sheet
|Coved vinyl skirting
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|
|}
'''PART E – Examples and case studies'''

Figure 4 demonstrates the relationships between the zones within the mortuary. In this example it is evident how visitors are managed and kept out of the working portions of the mortuary through segregation in the internal layout. The process flow of the bodies into, through and out of the mortuary has been well considered in that the flow is linear with bodies entering the mortuary <s>on</s>at one end of the facility and exiting at the other. Unfortunately, the restrictions presented by the location of the mortuary, as can be studied in Figure 3, has forced the design into a number of compromises relating to the external flow and access to the mortuary. Staff access is quite severely compromised in being through the mortuary lobby. This mortuary lobby, in the absence of a dedicated preparation room, has the potential of being used as one. This arrangement may impact negatively on the dignity of some staff, the dignity of the deceased, and mortuary security.

Visitors’ access to the mortuary and their adjacent toilets is near the hearse bay and turning areas. There is no natural screening of this entrance from the activities in the hearse bay and it is not inconceivable that visitors may inadvertently wander into the wrong area and be exposed to operational activities not appropriate for the bereaved.

The door sizes of the body storage rooms seem too small for the easy passage of a body trolley when compared to the double doors made available for the passage of the body from there through the remainder of the facility. Door size selection should not be limited by the fact that these are cold room doors. Where doors are too small for free passage of trolleys and porters, <s>their</s> the doors’ service life would be severely shortened and any savings made on the door selection would be lost to maintenance or retrofitting an improved solution.

The access to the technical area for maintenance of the refrigeration equipment in this example meets the recommendations. Here technicians do not need to enter the mortuary to perform the majority of their work and these areas are quite well separated from the admin and visitors’ areas.

 

# EXAMPLE 2: LARGE MORTUARY WITH AUTOPSY FACILITIES

Figure 5 shows the layout of a standardised mortuary design. This is a large facility with autopsy capacity. Figure 6 has been presented in order to promote an understanding of the interrelationship between the various functional parts of the mortuary.

Considering the entrances shown in Figure 5, it is clear that the designer has <s>taken some</s>made an effort to screen the <s>visitor’s</s> visitors’ entrance from the hearses’ entrance. The staff entrance is also well positioned. The staff ablution<s>s</s> facilities and showers are located between the clinical areas and the admin areas. This arrangement encourages good segregation and gowning practice when moving between the mortuary activities and external movement.

The staff and visitors’ access positions are located well away from the working clinical areas of the mortuary and are also relatively remote from each other. This aids in improving security as it discourages the staff and visitors from using the wrong entrances and thereby assists in identifying persons who are present in areas where they do not belong.

This design doesn’t have a dedicated body prep area and it is assumed that the weighing and measuring area is therefore used for this purpose.

The large sliding doors of the cold room in this example can be compared to the cold-room doors in Figure 3 as an indication of what the door size should be like to enable easy passage.

The layout in this example does not provide for a dedicated exit yard and bodies and hearses entering and leaving the facility do so through the same entrance. This arrangement increases the potential for mistakes in body handling.

The common use of the bier room as access to the ID room seems to be a compromise resulting from the limited space provided for these rooms. {{Expand}}
[[Category:Procurement and Operation]]

Maintenance

2022-07-22T08:50:26Z

Tmojanaga: Adding text

Contents

OVERVIEW 5<s>6</s>

'''''Abbreviations''''' 9<s>8</s>

PART A – POLICY AND SERVICE CONTEXT 11<s>9</s>

Legislation, policies and international guidance 11<s>9</s>

1. LEGISLATIVE CONTEXT 11<s>9</s>

2. Further reference material and precedent<s>:</s> 11<s>9</s>

3. INFECTION PREVENTION AND CONTROL LEGISLATION 12<s>10</s>

4. BUILDING LEGISLATION 12<s>10</s>

5. SOUTH AFRICAN BUILDING PRACTICE POLICY AND GUIDELINES 12<s>10</s>

6. INTERNATIONAL DESIGN GUIDANCE 12<s>10</s>

Service Context 13<s>11</s>

PART B – PLANNING AND DESIGN 15<s>12</s>

1. INTRODUCTION 15<s>12</s>

2. LOCATION OF THE MORTUARY AND ACCESS ROUTES 16<s>13</s>

3. FACILITY CAPACITY 16<s>13</s>

4. SELECTING BODY STORAGE SYSTEMS 18<s>14</s>

5. FACILITY LAYOUT 18<s>15</s>

6. MORTUARY EQUIPMENT REQUIREMENTS 21<s>17</s>

7. MOVEMENT WITHIN A MORTUARY 22<s>18</s>

8. SERVICES REQUIRED 24<s>19</s>

9. BIOLOGICAL SAFETY 24<s>19</s>

10. FINISHES TO FLOORS AND WALLS 25<s>20</s>

11. AUTOPSY EQUIPMENT/FIXTURES 26<s>20</s>

12. VENTILATION 27<s>21</s>

13. AIR CONDITIONING 27<s>22</s>

14. REFRIGERATION EQUIPMENT DESIGN AND INSTALLATION 28<s>22</s>

15. SECURITY ARRANGEMENTS 28<s>22</s>

PART C – OPERATION 30<s>24</s>

1. OBJECTIVES 30<s>24</s>

2. HEALTH AND SAFETY 30<s>24</s>

3. MAINTENANCE 30<s>24</s>

PART D –USER ROOM REQUIREMENTS 32<s>32</s>

Room Requirement Sheets 32<s>32</s>

PART E – EXAMPLES AND CASE STUDIES 36<s>35</s>

Layout Examples 36<s>35</s>

1. EXAMPLE 1: SMALL MORTUARY ATTACHED TO HOSPITAL 38<s>36</s>

2. EXAMPLE 2: LARGE MORTUARY WITH AUTOPSY FACILITIES 39<s>37</s>

3. EXAMPLE 3: LARGE MORTUARY WITH AUTOPSY FACILITIES 43<s>40</s>

BIBLIOGRAPHY 46<s>42</s>

'''Table of Figures'''

Figure 1 Adjacency Diagram 1<s>16</s>

Figure 2: Access and Movement in a mortuary 1<s>18</s>

Figure 3 Example 1: Layout 1<s>35</s>

Figure 4 Example 1: Zoning & Access 1<s>36</s>

Figure 5 Example 2: Layout 1<s>38</s>

Figure 6 Example 2: Zoning and Access 1<s>39</s>

Figure 7 Example 3: Layout 1<s>40</s>

'''Table of Tables'''

Table 1 : IUSS Reference documents 8<s>7</s>

Table 2 Service Requirements 13<s>11</s>

Table 3 Accommodation Schedule 32<s>25</s>

TABLE 4 ROOM SERVICES SHEET 33<s>26</s>

TABLE 5 ROOM FINISHES 34<s>27</s>

''Version Control''
{| class="wikitable"
|''Template''
|''January 2013''
|''Tobias van Reenen''
|-
|''Discussion Draft 1''
|''February 2013''
|''Steve Fourie''
|-
|''Discussion Draft 5''
|''March 2013''
|''Steve Fourie''
|-
|''Discussion Draft 6''
|''May 2013''
|''Steve Fourie''
|-
|''Development Draft 1''
|''August 2013''
|''Tobias van Reenen''
|-
|''Development Draft 3.1''
|''February 2014''
|''Tobias van Reenen''
|-
|''Development Draft 3.1''
|''February 2014''
|''Prof J Vellema''
|}

Page Break

OVERVIEW

This document outlines the policy and service context and attempts to illustrate the desired planning principles and design considerations for mortuary services.

* ''Part A'' outlines the South African legislation, policies and international guidance reference documents and the service context with respect to mortuary services;
* ''Part B'' Planning and design;
* ''Part C'' operation;
* ''Part D'' user room requirements; and
* ''Part E'' provides case studies.

Parts D and E are intended to demonstrate how the principles prescribed in Part A, B, and C can be applied in worked examples. Part D, if used directly, are deemed<s>-</s> to<s>-</s> satisfy the principles developed in Part B, but are not the only acceptable solutions.

Case studies (Part E) provide illustrative worked solutions and should not be adopted without appropriate contextual adaptation.

While this document outlines design requirements and acceptance criteria which have an impact on clinical services, these requirements are prescribed within the framework of the entire IUSS set of guidance documents and cannot be viewed in isolation. The following documents should be complied with, together with this document:

* IUSS: Regulations
* IUSS: Project Planning and Briefing
* IUSS: Environment and Sustainability
* IUSS: Hospital Design Principles
* IUSS: Infection Prevention and Control

Page Break

The following table identifies additional IUSS guideline documents which are recommended for reading in conjunction with this guideline.

'''Table 1 : IUSS Reference documents'''
{| class="wikitable"
|

'''CLINICAL'''

'''SERVICES'''
 
|Essential
|Recommended
|'''SUPPORT'''

'''SERVICES'''
|Essential
|Recommended
|'''HEALTHCARE ENVIRONMENT/ CROSSCUTTING ISSUES'''
|Essential
|Recommended
|'''PROCUREMENT'''

'''& OPERATION'''
|Essential
|Recommended
|-
|Adult Inpatient Services
|
|X
 
|Administration and Related Services
|
|
|Generic Room Requirements
|
|
|Integrated Infrastructure Planning
|
|
|-
|Clinical and Specialised Diagnostic Laboratory Guidelines
|
|X
|General Hospital Support Services
|
|X
|Hospital Design Principles
|
|
|Briefing Manual
|
|X
|-
|Mental Health
|
|
|Catering Services for Hospitals
|
|
|Building Engineering Services
|X
|
|Space Guidelines
|
|
|-
|Adult Critical Care
|
|
|Laundry and Linen Department
|
|X
|Environment and Sustainability
|
|
|Cost Guidelines
|
|
|-
|Emergency Centres
|
|
|Hospital Mortuary Services
|
|
|Materials and Finishes
|X
|
|Procurement
|
|
|-
|Maternity Care Facilities
|
|
|Nursing Education Institutions
|
|
|Future Healthcare Environments
|
|X
|Commissioning Health Facilities
|X
|
|-
|Adult Oncology Facilities
|
|
|Health Facility Residential
|
|
|Healthcare Technology
|
|
|Maintenance
|X
|
|-
|Outpatient Facilities
|
|X
|Central Sterile Service Department
|
|
|Inclusive Environments
|
|
|Decommissioning
|X
|
|-
|Paediatrics and Neonatal Facilities
|
|
|Training and Resource Centre
|
|X
|Infection Preventive Control
|X
|
|Capacity Development
|
|
|-
|Pharmacy
|
|
|Waste Disposal
|
|X
|Health Informatics
|
|
|
|
|
|-
|Primary Health Care Clinics and CHCs
|
|
|
|
|
|Regulations
|
|
|
|
|
|-
|Diagnostic Radiology
|
|
|
|
|
|
|
|
|
|
|
|-
|Adult Physical Rehabilitation
|
|
|
|
|
|
|
|
|
|
|
|-
|Sub-acute services
|
|
|
|
|
|
|
|
|
|
|
|-
|Facilities for Surgical Procedures
|
|
|
|
|
|
|
|
|
|
|
|-
|TB Services
|
|
|
|
|
|
|
|
|
|
|
|}

'''''Abbreviations'''''
{| class="wikitable"
|ACH
|Air changes per hour
|-
|ASHRAE
|American Society of Heating, Refrigerating, and Air-Conditioning Engineers
|-
|BMS
|Building Management System
|-
|BSL
|Biological safety level
|-
|CDC
|Centers for Disease Control (USA)
|-
|CSIR
|Council for Scientific and Industrial Research
|-
|FD
|Floor drain
|-
|FPS
|Forensic Pathology Service
|-
|HVAC
|Heating Ventilation Air Conditioning
|-
|HBA
|Hazardous biological agents
|-
|HCS
|Hazardous chemical substances
|-
|HEPA
|High efficiency particulate air filters
|-
|IPC
|Infection prevention and control
|-
|ISO
|International Standards Organisation
|-
|MDR TB
|Multi-drug resistant TB
|-
|NDoH
|National Department of Health
|-
|NBR
|National Building Regulations
|-
|<s>NDoH</s>
|<s>National Department of Health</s>
|-
|NHS
|National Health Service (UK health service)
|-
|NIOSH
|National Institute of Occupational Safety and Health (US agency)
|-
|O&M
|Operating and Maintenance (manual)
|-
|OHS
|Occupational health and safety
|-
|OQ
|Operational qualification
|-
|PGWCDoH
|Provincial Government Western Cape Department of Health
|-
|PPE
|Personal protective equipment
|-
|PQ
|Performance qualification
|-
|RDS
|Room data sheets
|-
|RH
|Relative humidity
|-
|SABS
|South African Bureau of Standards
|-
|SAO
|Senior Administrative Officer
|-
|SAPS
|South African Police Service
|-
|SI
|<s>Le Systeme International d' Unites</s> Le Système International d’Unités
|-
|SOP
|Standard Operating Procedures
|-
|SS
|Stainless steel
|-
|TB
|Tuberculosis
|-
|WC
|Toilet
|-
|WHB
|Wash-hand basin
|-
|WHO
|World Health Organisation
|-
|XDR TB
|Extreme (or extensively) <s>-</s>drug- resistant TB
|-
|
|
|-
|
|
|-
|
|
|}
PART A – Policy and service context

Legislation, policies and international guidance
 

# LEGISLATIVE CONTEXT

The following documents, as amended (though not an exhaustive list) pertain and contain an additional resource of information which would supplement and provide the basis of a design brief. A finer sense of standard operating procedures and legislative context is likely to inform and enhance the design process, so the professional teams are encouraged to use these as an additional resource:
 

* Inquest Act<s>,</s> 58, 1959
* National Health Act<s>,</s> 61, 2003
* Government Notice R363, 2013 [Regulations relating to the management of human remains]
* Government Notice R178, 2012 [Regulations relating to the registration of microbiological laboratories and the acquisition, importation, handling, maintenance and supply of human pathogens]

* Health Professions Amendment Act, 29, 2007
* Criminal Procedures Act<s>,</s> 51, 1977
* Births and Deaths Registration Act<s>,</s> 51, 1992
* National Environmental Management: Waste Act<s>,</s> 59, 2008
* National Archives of South Africa Act<s>,</s> 42, 1996

* Regulations regarding the Rendering of Forensic Pathology Service, ''Government Gazette'' No 30075. No R636, 20 July 2007
* Space Planning Norms and Standards for Office Accommodation used by Organs of State, ''Government Gazette'' No 27985. No 1665, 2 Sept 2005
* Western Cape Health Care Waste Management Draft Bill
* Municipal by<s>-</s>laws, as applicable
* National Code of Guidelines for Forensic Pathology Practice in South Africa, 20 Aug 2007

* Standard Operating Procedures, Forensic Pathology Service, PGWCDoH, 2006
* Biosafety in Microbiological and Biomedical Laboratories, U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention and National Institutes of Health, Fifth Edition, <s>2007</s> US Government Printing Office, Washington: 2007

 

# Further reference material and precedent<s>:</s>

 

* Standard specification for air-conditioning and ventilation systems, Western Cape Department of Public Works, 1998
* Fire security: a guide for architects, Western Cape Department of Public Works, 1998
* Standard electrical specification, South African Department of Public Works, 2005
* Facilities for mortuary and post-mortem room services, NHS Estates, 2001, ISBN 0-11-322000-00
* Part B – Health facility briefing and planning, Australasian Health Facilities Guidelines, 2007

* CKS 336: 2013 Mortuary Trolleys - SABS

# INFECTION PREVENTION AND CONTROL LEGISLATION

The National Infection Prevention and Control Policy and Strategy document makes specific reference to certain Acts and their relevant regulations, which bear relevance to the development and implementation of these health facility guidelines. These are:

* The South African Constitution, 1996 [Sections 2, 24, 27, 36 and 39], as amended
* The Occupational Health and Safety Act of 1993, Act No 85 of 1993 [Section 8(1)]

* Government notice R1390 of 27 December 2001 [Hazardous Biological Agents Regulation] as promulgated under Section 43 of the Occupational Health and Safety Act of 1993
* Government notice R908 of 27 June 2003 [Hazard Analysis Critical Control Point Regulation] as promulgated under Section 15(1) of the Foodstuffs, Cosmetic and Disinfectants Act of 1972
* The Environmental Conservation Act of 1989, Act No 73 of 1989
* The Foodstuffs, Cosmetic and Disinfectants Act of 1972, Act No 45 of 1972

 

# BUILDING LEGISLATION

The following legislation and regulations impact and provide guidance on the provision and design of health care facilities as above:

* The National Environmental Management Act 107 of 1998, as amended
* Building regulations and Building Standards Act 103 of 1977, as amended
* National Building Regulations; SANS 10400:2010, Code of Practice for the Application of the National Building Regulations

* Promotion of Equality and Prevention of Unfair Discrimination Act No 4 of 2000
* General Procedures and Loadings adopted in the Design of Buildings, SABS 0160, 1993
* Structural Use of Concrete Design, SABS 0100-1, 1992
* Structural Use of Concrete – Materials and Execution of Work, SABS 0100-2, 1992
* Specification for Civil Engineering Construction SABS 1200

 

# SOUTH AFRICAN BUILDING PRACTICE POLICY AND GUIDELINES

* R158 of 1980 regulations pertaining to Private Hospitals and Unattached Operating Theatres – R198
* Good Pharmacy Practice, Board Notice 129 of 2004, as amended [see Chapter 1].

# INTERNATIONAL DESIGN GUIDANCE

* ASHRAE Standard 52.2, “Method of Testing General Ventilation Air-Cleaning Devices for Removal Efficiency by Particle Size”, 1992, 1999b
* ASHRAE Standard 62, “Ventilation for Acceptable Indoor Air Quality”, 1989
* ASHRAE. “HVAC Design Manual for Hospitals and Clinics, 2003”, 1989
* CIBSE Applications Manual AM10:1997 “Natural Ventilation in Non-Domestic Buildings”, 1998
* CIBSE Applications Manual AM13:2000 “Mixed Mode Ventilation,” 2000

* ASHRAE Standard 170, “Ventilation of Health Care Facilities”, 2008
* QASA. “Know Your Rights” [Accessibility & the Built Environment]
* Department of Health and Human Services. “Environmental Control for Tuberculosis: Basic Upper-Room Ultraviolet Germicidal Irradiation - Guidelines for Healthcare Settings”, 2009
* WHO. “WHO Policy on TB Infection Control in Health-Care Facilities, Congregate Settings and Households”, 2009

Guidance has also been provided by AIA (USA), NHS (UK), and Australian Health Facility Guidelines on Healthcare Building Design. Additional references can be sourced from www.tb-ipcp.co.za

Service Context

The following table gives an indication of the service requirements for mortuaries within different types of public hospitals.

Table 2: Service Requirements
{| class="wikitable"
|'''Service'''
|'''District'''
|'''Regional'''
|'''Tertiary'''
|'''Central'''
|'''Specialised'''
|-
|Small (beds)
|50-150
|Min 300
|Min 400
|
|
|-
|Medium (beds)
|150-300
|
|
|
|
|-
|Large (beds)
|300-600
|Max 800
|Max 800
|Max 1200
|Max 600
|-
|Training
|Where practical
|Where practical
|Optional
|Yes. Attached to medical school
|
|-
|Conduct research
|
|
|
|Yes
|
|-
|'''Mortuary'''
|
|
|
|
|
|-
|Short-term stay (2˚C)
|Yes
|Yes
|Yes
|Yes
|
|-
|Long-term stay (-15˚C)
|Yes
|Yes
|Yes
|Yes
|
|-
|Autopsies (20°C -21°C)
|Yes
|Yes
|Yes
|Yes
|Yes
|}

For the determination of capacity requirements of mortuaries refer to the recommendations further on in this document.

This guidance document relates to mortuaries located within and serving hospitals, with respect to persons that die due to natural causes in that hospital. This document excludes mortuaries <s>exclusively</s> dealing exclusively with cases that require medico-legal investigation of deaths from unnatural causes.

Post mortems conducted in hospital mortuaries should be limited to conducting investigations and procedures where no medico-legal investigation is required and death from natural causes is suspected.

Hospital deaths from natural causes and those suspected to be of unnatural cases should not be managed in the same facility unless the hospital mortuary is equipped to comply with the specific legal requirements as <s>it</s> they relate<s>s</s> to the chain of evidence, etc. The requirements for forensic- pathology service mortuaries are not exhaustively detailed in this document.

It is also noted that some hospitals may opt to contract out the removal and storage of decedents to private undertakers and these hospitals may <s>only</s> require only the minimum in terms of refrigerated body storage.

PART B – Planning and Design

# INTRODUCTION

# All state- run mortuary facilities fall within the domain of the Department of Health, both National and Provincial;<s>,</s> and in an effort to provide engineers and architects who are required to either design new facilities or upgrade existing facilities, this document provides the minimum standards necessary to comply with existing legislation.

# This document will provide designers of this type of facility with guidelines as to what is required in terms of the following:

* Type of service and package of care being provided
* Mortality rate
* Access and egress
* Discreet management of human remains

* Size and dimensions of the actual facility
* Positioning of mortuaries within hospitals
* Finishes of surfaces in these facilities
* Water- supply requirements
* Drainage requirements

* Electrical supply and lighting requirements
* Installation requirements for equipment and services
* Body-storage requirements
* Body-handling facilities
* Body-holding areas

* Body-viewing area
* Autopsy equipment (tables)
* Air conditioning and ventilation requirements (for infection and indoor air quality control)
* Security of the facility

# In addition to the items listed above, it is also necessary to consider the needs of visitors to these facilities, particularly those wishing to, or who are required to, identify bodies. In line with this it is also necessary to take the handling of bodies into consideration as it pertains to issues of patient dignity.

# Forensic pathology mortuaries are not <s>considered</s> exhaustively described in this document, although the majority of mortuaries do have basic facilities for general autopsies that are not necessarily medico-legal in nature. A forensic pathology mortuary has laboratory facilities attached that are outside the scope of regular mortuaries found in hospitals and at police stations. It should be noted that there are a number of principles that hold true for both hospital and forensic pathology mortuaries.

# Compliance with the requirements of the Occupational Health and Safety Act (Act 85 of 1993 as amended) are to be complied with at all times during the design of a mortuary.

 

# LOCATION OF THE MORTUARY AND ACCESS ROUTES

# The position of the mortuary in a hospital should be such that the mortuary is easily accessible to mortuary staff and related service providers without presenting either aesthetic, emotional or ethical problems for unrelated hospital staff, patients or visitors. Visitors to the mortuary, however, should be provided with clear and direct access to the mortuary upon arrival at the hospital, without having to travel unnecessarily through hospital departments.

# Where bodies are moved into or out of the mortuary, they should not be moved through general public-access areas. Appropriate routes would include technical service or goods corridors and through the hospital’s support services yard.

# Special considerations should be given to plans for contingency access to the mortuary in the event of case- load surges, which may <s>be</s> result from disasters.

# Bodies should not be held for any period in any locations between the body- holding rooms within clinical areas and the mortuary.

# Where a mortuary unit is used jointly between the hospital and the local authority it is beneficial for the mortuary to be in a building separate from the main hospital building.

# The delivery of bodies to the mortuary and their subsequent removal from the facility is to be such that it is carried out in a manner that is not visible to the general public, preferably in a covered and enclosed area.

# While siting and access are important aspects when locating a mortuary, it is also important to provide the mortuary with pleasant surroundings in order to promote the dignity of those working in or visiting the mortuary.

 

# FACILITY CAPACITY

# The layout and size of a mortuary is largely determined by the number of bodies stored and whether body storage needs to be in cabinets or in refrigerated rooms.

# In order to determine the storage capacity of a hospital mortuary it is recommended that historical data, where available, should be used. In the South African context it is suggested that a storage capacity of between 5 and 10 bodies per 100 beds should be used. This varies with the rural or urban location of the facility. This capacity should not take into account the need to store bodies from deaths which are not hospital related, typically motor-vehicle accident deaths and deaths from criminal activity. Requirements for contingency storage capacity related to disaster management should be considered.

# The body storage capacity required can be estimated on the basis of the number of deaths per year in the hospital, the length of time of holding and the required body store occupancy rate. The number of body trays can be calculated from Equation 1<s>Equation 1</s> below.

-Equation 1

Where:

BT = Number of body trays

D = Number of deaths per year requiring body trays

S = Average length of stay (in days)

R = Required body tray occupancy rate

[Text Box]

# The estimated storage capacity for bodies in a mortuary could be confounded by a number of local factors, such as:

* Mortality rate from natural causes.
* Mortality rate from infectious disease. (Highly contagious disease deaths require special storage facilities.)

# Where the hospital is expected to place the body in cold storage until collection by forensic pathology services the following additional factors should be considered:

* Mortality rate from foul play.
* Mortality rate from traffic incidents.

 

# SELECTING BODY-STORAGE SYSTEMS

# Body-storage systems are principally divided into refrigerated rooms or body cabinets. Differences within these system types occur where specific temperatures or sizes are required based on risk, need and capacity requirements.

# Where a system of functionally separate body cabinets is selected, this system would have an inherent redundancy against failure, as the failure of a single unit would not necessarily imply a system failure. In contrast, a refrigerated room would require less maintenance and would have a lower frequency of failure; however a single component failure could be critical if standby condensing units are not installed. For this reason, multiple- cabinet systems are recommended for areas where expected maintenance response times would negatively affect the mortuary’s operations.

# It is possible to have a requirement for a mixture of refrigerated rooms and body cabinets. This could be affected by local cultural requirements such as for families <s>which</s> who object to bodies sharing storage space, the case load of the facility or the case profile.

# Where there is a requirement for the long-term storage of bodies, these are to be kept at a lower temperature than would be the case in a refrigerated room. In this instance separate body cabinets are required. Long- term storage of bodies is most often required when an indigent person dies and difficulty is experienced in locating the next of kin, as the person cannot legally be buried until this process has been completed.

# In general, smaller facilities rely on body cabinets for the storage as these facilities do not have the space or the need for the large-scale storage of bodies, <s>and they do not</s>they would not appreciate the functional flexibility offered by these systems. By rule of thumb, any facility that has the requirement to store <s>less</s> fewer than 12 bodies at any given time should use body cabinets. This <s>provides</s> gives the option of providing both short- and long-term storage with the smallest facility and equipment footprint.

# Bodies suspected of having succumbed to a highly contagious and dangerous disease require special treatment. These should be stored in such a manner that they do not present a hazard to personnel working in the mortuary. Typically these bodies should be stored at the same temperature<s>s</s> <s>the same</s> as <s>for</s> long- stay bodies, e.g. -15˚C, and should be placed in hermetically sealed plastic body-bags.

# Provision for the secure cold storage of body parts should <s>also</s> be provided.

 

# FACILITY LAYOUT

# As mentioned, the layout and size of a mortuary is going to be largely determined by case load and whether storage is in cabinets or refrigerated rooms. It is acceptable to have a mixture of refrigerated rooms and body cabinets.

# In a mortuary facility there are a number of separate areas that need to be considered other than the body- storage areas. These include:

# '''Reception area''' for members of the public who are required to visit the mortuary on official business – typically to identify bodies or to pay their last respects to a deceased person.

# '''Ablution areas''' for staff. Where unisex ablutions are provided it is recommended that <s>the</s> no urinal is provided.

# <s>'''Visitor’s'''</s> '''Visitors’ admin space''' close to the reception area, where any admin or official business related to the identifying of a body can be completed.

# '''Staff admin space''' close to the point where a body is delivered to the mortuary, so that pertinent documentation can be completed – both with respect to the delivery of the body, as well as when the body is released from the mortuary again.

# '''Office space''' for pathologists to write up reports <s>for</s> in instances where this could be required. This is dependent on the size of the mortuary as small facilities would not require a separate room(s) for this function.

# '''Waiting''' and circulation areas for visitors to the mortuary.

# '''Viewing room,''' from where a body can be viewed through a curtained glass window between this space and the body- display room.

# '''Body- display''' room, where a body is placed for identification purposes. There is to be access to this area via a lockable door to the viewing room <s>for</s> in instances where it is necessary for non-mortuary personnel to have direct access to a body in the viewing room. There is to be access to this room from the body- storage area to allow bodies to be brought in for display purposes.

# '''Body preparation''' area, where a body that is delivered to the mortuary needs to be attended to prior to it being placed in the viewing room.

# '''Shower facilities''' (staff)

# '''Changing room''' (staff)

# '''Storage space''' for equipment and clothing that is worn in the body-preparation and autopsy spaces.

# '''Body-storage''' facility (cold room or refrigerated cabinets), depending on the length of time that bodies are expected to be kept in the facility.

# '''Autopsy facility,''' where the cause of death can be determined. This facility will differ from mortuary to mortuary, depending on whether forensic or standard medical autopsies to determine the cause of death are conducted.

[GroupDrawing]
 

# Figure 1<s>Figure 1</s> is an example of an adjacency diagram for a typical mortuary. In this instance the proximity also relates to visual and physical access. It is also understood that not all mortuaries would require all of the spaces indicated in this diagram, and that some of the spaces shown as being '''''immediately adjacent''''' could be included as a single area if functionality and privacy considerations permit it.

# There remains abundant scope for variations in the planning of the layouts making up the mortuary. and the hospital architect should consult with all stakeholders to arrive at an ideal solution.

# When developing the facility layout, careful consideration should be given to the routes through the facility of staff, bodies and visitors. These routes should overlap as little as possible and there should never be a common entrance for bodies and staff or visitors.

# The room requirement sheets are presented in ''PART D – User Room Requirements<s>PART D –User Room Requirements</s>''of this document.

# Storage space for body lifts must be provided.

# Suitable sluicing facilities are required to be able to clean equipment and fabrics after completion of any work in the mortuary facility.

 

# MORTUARY EQUIPMENT REQUIREMENTS

# Equipment for storage and transportation of bodies should meet environmental hygiene standards.

# For mortuary trolley design and supply, the SABS published standard '''''CKS336:2013 Mortuary Trolleys''''' is recommended. It should be noted that this is not a normative South African National Standard, and individual requirements may differ.

# '''Body-cabinet''' selection and installation requires the following considerations:

# Three-level body cabinets could be selected which have a single door to give access to all of the body trays, for instances where separation between bodies is required. Alternatively, cabinets that provide a single door for access to all the body trays are acceptable.

# It is critical that bariatric (obese) bodies are catered for in each cabinet. The lowest-level tray should be designed for this purpose.

# Special consideration is to be given to the provision of capacity for storage of juvenile and infant decedents. The handling of these bodies is an especially sensitive and emotive issue, and separate storage in dedicated cabinets is recommended.

# Body lifts must be supplied to facilitate the loading of bodies into and removal of bodies from the cabinets. Body lifts help to preserve dignity when handling bodies, while at the same time making it easier and safer for mortuary personnel to handle bodies.

# A clear space must be provided in front of the body cabinets to allow for the placing of a corpse into the cabinets. It is recommended that there be at least a 3m clearance between the front of the cabinet and any fixed structure. This is to accommodate whatever means of conveyance is used to transport a corpse to ?? and then load it into the cabinet.

# Due to the vast array of cabinets available on the market and the lack of an appropriate national standard, it is not yet possible to prescribe sizes for refrigerated cabinets in this guide.

# The required cabinet size is fundamental when designing a mortuary. Where space is not too limited and there are no indications that there may be cultural concerns relating to the storage of bodies together in a cold room, it is recommended that cold rooms be used. Cold rooms offer space savings when compared to cabinets.

# A temperature gauge must be installed close to the door of the facility to indicate the storage-space temperature. This gauge should have an alarm system connected to it to give a warning should there be an unacceptable rise in temperature in the storage space. Typically, if the temperature should rise more than 2˚C above the set temperature, an alarm should be activated at a point that is manned at all times.

# Body cabinets and refrigerated rooms must be supplied with electrical power from the hospital’s essential services electrical supply.

# A slop hopper is to be provided to allow for the cleaning of the body preparation and autopsy areas, in particular after the completion of any work carried out in these areas.

# To allow for the rinsing of body parts and organs, during an autopsy procedure it is important that suitable basins be provided in close proximity to <s>the</s>a downdraft autopsy table.

# Where there is transition between “clean” and “dirty” areas, provision is to be made to allow for the cleaning of footwear in a “transitional” area. This helps prevent the transport of contaminants from dirty areas.

 

# MOVEMENT WITHIN A MORTUARY

# Movement of members of the public visiting the mortuary is to be restricted such that they do not have access to the body- preparation or autopsy areas. (Figure 2<s>Figure 2</s>)

# The facility must be available within the mortuary where body identification can be conducted in a private and dignified manner. This viewing area should consist of a body- display or layout room with an adjacent viewing room, where the body can be viewed through a curtained shatter-proof glass window.

# The requirement for a viewing and identification area also pertains to hospitals which outsource their mortuary services.

# The viewing room and visitors’ admin rooms should be designed such that counselling can be conducted in a pleasant environment for bereaved persons.

# The design of the viewing facility should allow <s>for</s> adequate space for persons to view a body in a dignified manner.

# Direct access to the body- layout room from the viewing room is to be provided via a lockable door, to allow visitors access to the body.

# Ablution facilities are to be available to members of the public who are required to visit the mortuary complex.

# [GroupDrawing]Where a dedicated room, as described above, cannot be allocated for placing a body for viewing purposes, the persons who are viewing a body should be given a private space for viewing the body through a curtained shatter-proof glass window, as a minimum.

# Adequate facilities to accommodate at least 7 visitors are to be provided.

# Staff access to the mortuary facility is to be separate from the general public. (Figure 2)

# Mortuary staff change rooms should be provided with secure lockers for storage of street garments, lab coats, personal protective equipment and valuables. <s>Street garments and lab garments</s>

# Mortuary staff may have completely separate ablution facilities from those used by the general public requiring access to the mortuary facility.

# In a free- standing mortuary building the delivery to and removal of bodies from the facility may be via the same access point to the building.

# A mortuary that forms an integral part of a hospital will require separate routes for receiving bodies and the subsequent removal thereof.

# In the unusual event that a body arrives from outside <s>of</s> the hospital, the normal route of removal should be used for receipt of the body.

# A clear distinction is to be made between “clean”,” “dirty” / “wet” and “transitional” areas. This is best achieved by creating a physical “RED LINE” on the floor indicating the separation of these areas, with “yellow lines” used to demarcate “transitional” areas. Receptacles for the collections of dirty clothing, etc, must be made available at the transition area from <s>a</s> dirty to clean areas and in change rooms.

# A well-drained facility for washing <s>of</s> vehicles which have been contaminated with decomposed bodies or <s>bodily</s> body fluids should be provided in an enclosed area, near to the mortuary.

 

# SERVICES REQUIRED

# Hygienic floor drains that are resistant to corrosion from blood and chlorine should be provided in all “wet areas” of the mortuary and should be directly connected to the sewer system. These areas include body preparation, autopsy space, etc. These areas require thorough cleaning after every procedure, using large quantities of water and decontaminating and disinfecting chemicals and soaps.<s>.</s>

# Sluicing facilities are to be provided in both the body- preparation and autopsy areas if they are not a common area.

# Open floor channels should be avoided. Where this is not possible, these should be covered by durable, flush- fitted stainless steel grids.

# No sewer connections external to the mortuary services should be made to the line between the wet area drains and the main sewer system in order to prevent backflow to other areas.

# The provision of hot and cold water in the facility is imperative, with all basins, sinks, ablution areas and autopsy tables being provided with both.

# Anti-backflow devices should be fitted to the water- supply lines serving mortuary table faucets to prevent backflow should supply water pressure fail.

# Electricity supply to the mortuary – particularly for refrigeration purposes – is to be provided from the essential supply system for the hospital. Alternatively, a back-up generator is to be supplied to allow for the maintenance of required temperatures in the cooling/freezing facilities in the mortuary.

 

# BIOLOGICAL SAFETY

# A Biosafety Laboratory Level 3 (BSL3) designation (R178-2012) is applicable for any decomposing bodies post-mortem area. This area is identified as a level-3 containment facility.

# BSL3 areas shall have restricted access and shall be separated from regular traffic flow routes.

# All doors opening into the BSL3 areas shall be appropriately labelled with biological safety hazard signage.

# Access to the BSL3 areas shall be through dedicated ventilated airlocks. A pressure differential of minimum +15Pa shall be maintained for the airlock relative to the BSL3 area. This pressure differential is relevant for when the doors are closed only. Room pressure differential gauges are to be fitted at the entrance to the BSL3 area.

# Airlock doors shall be interlocked such that only one door can be opened at a time, thereby preventing direct passage between the corridor and the BSL3 area.

# It is recommended <s>to create</s>that a transfer hatch be created for the transfer of goods between areas with differing biosafety-level classifications. This device shall be designed to preserve the integrity of the containment system and the mechanical ventilation design.

# Air exhausted from biosafety areas should be safely discharged to the outside with no chance for re-entrainment or contamination of other indoor spaces. Exhausts from biosafety areas should be vented at 3m above the roof level. Where such measures are not possible, exhaust air shall be EN1822 H13 HEPA filtered. Exhausts from biosafety areas should include anti-backflow devices.

 

# FINISHES TO FLOORS AND WALLS

# Walls and floor coverings within a mortuary should be easily cleanable and impervious to liquids and staining.

# Floors are to be of such a nature that they are not easily damaged by wheeled items that are moved over them. Vinyl floor coverings are not considered to be resilient enough for this purpose.

# Epoxy floor coverings are preferable, as these are easily maintained and do not have joints in them where liquids can accumulate to become a health risk.

# Corners between walls and floors shall be coved to facilitate the cleaning of these areas. These coving details should be solid and continuous without hidden formwork and cavities.

# Walls are to be coated with hard- wearing and washable materials/paint with provision made for trolley “bumpers” along walls exposed to high traffic. Wall coatings shall be impervious to damage from trolleys and mobile equipment.

# Materials such as vinyl sheeting should not be used to cover walls in wet areas. The risk of growth between the sheeting and the wall presents a health hazard to personnel working in the mortuary wet areas.

# Due to the potential presence of water on flooring it is essential that flooring be non-slip.

# Refer to the room requirement sheets herein and the '''''IUSS Materials and Finishes''''' guidance documents for further information.

# Surface- mounted services should be avoided to ensure smooth and washable surfaces. Where surface mounting of piping is unavoidable, this piping should be mounted on batons, such that the space behind the piping is readily accessible for cleaning.

 

# AUTOPSY EQUIPMENT/FIXTURES

# Equipment for the storage and transportation of bodies should meet environmental hygiene standards.

# In the majority of instances a<s>n</s> downdraft autopsy table is required within a hospital mortuary facility. This table should be one that is designed in such a way that there is a hot and cold water supply that is integral to table installation, as well as a drainage system that can automatically drain water/waste from the table to the sewer system of the facility.

# The autopsy table should have an integrated ventilation extraction or “downdraft” system in order to entrain noxious odours and infectious material that may emanate from a body. This can function to minimise the spread of any airborne pathogens from the body.

# Adequate stainless steel washing basins (at least one per autopsy table) must be provided in close proximity to the autopsy table for the use of personnel working in the facility.

# Electrical power must be provided from a 5 amp IPX5 waterproof single-socket outlet near the autopsy table to allow for the safe use of any electrical equipment that may be required during an autopsy.

# Lighting quality over the autopsy table must be exceptionally good. Refer to the lighting requirements specified in the room- requirement sheets herein and the '''''IUSS Building Engineering Services''''' guidance document for specifications.

# Adequately sized worktops must be provided along the walls of the autopsy area for equipment and specimens prior to storage.

# It is recommended that working surfaces of at least 500x2500mm be provided per autopsy table.

# A balance table for a bench-top scale is required. The scale can be either permanently mounted on the work surface or stored in the autopsy equipment store.

# A platform scale for measuring the weight of an entire body prior to any possible dissection/autopsy work being conducted is to be accommodated.

# Lockable <s>C</s>cabinets are required for the storage of autopsy equipment, as well as for any personal protective equipment morticians or medical examiners may require.

# Trolleys for the conveyance of bodies must be provided in the mortuary and adequate provision for the storage of these units must be available.

# The use of wood, such as for wooden doorframes, is not allowed in wet areas.

# Stainless steel bump rails or plates should be fitted in areas prone to damage from trolleys. These devices shall be fitted such that that they do not affect the integrity and cleanability of the walls and floors. These devices shall not create crevices or gaps which could <s>would</s> harbour pathogens or create a hygiene problem. Welded stainless steel sections shall be stainless steel Grade 316L

 

# VENTILATION

# <s>Mortuaries</s> Mortuary areas require good ventilation. The exhaust air is to be discharged to atmosphere such that it cannot be drawn back into the mortuary, any other ventilation inlet, or any indoor portion of the hospital.

# All external ventilation openings should be fly- and vermin- proof.

# Exhausted air may not pose a hazard to any person who is outside the mortuary. (See room-requirement sheets) Air exhausted from clinical areas should be safely discharged to outside with no chance for re-entrainment or contamination of other indoor spaces. Where these precautions are by no means possible, exhaust air shall be EN1822 H13 HEPA filtered.

# Sufficient ventilation is required for controlling noxious odours present in mortuaries and should also provide a means of protection to personnel working in the facility from possible airborne infections originating from corpses.

# Airborne- infection control is of particular concern and must be designed for in terms of the ventilation system. Tuberculosis, Hepatitis and HIV are <s>of</s> among the most regularly encountered diseases in mortuaries in South Africa and, as such, the spread of these pathogens beyond the mortuary, via a ventilation system, must be avoided by implementing the airborne- contamination control principles for high- risk areas in the ventilation system design. Refer to the '''''IUSS Building Engineering Services''''' guidance document for further guidance on airborne- contamination control principles.

# The ventilation system must be designed such that airborne pathogens that may be present in the body- holding area and autopsy room do not contaminate the remainder of the mortuary facility.

# No recirculation of air extracted from the clinical areas is permitted.

# Air from public areas, with the exception of viewing rooms, may be recirculated where this is in accordance with the National Building Regulations.

# Exhaust ventilation is to be designed in such a manner that this extracts from the areas with the highest risk of infection, while “clean” air is to be supplied into the lower- risk areas. This is to create a pressure cascade with cleaner areas being at a relatively higher air pressure than dirty areas.

# Air- supply registers should be at a high level and the extraction registers should be at a low level. The low- level extraction grilles shall not be more than 500mm above the finished floor level of the room <s>where</s> from which the extraction is taken <s>from</s>. Low- level air- register positions shall consider locations of water points and potential splashing during washing.

 

# AIR CONDITIONING

# The mortuary and autopsy area must have a temperature maintained <s>at</s> between 20˚C <s>to</s> and 21˚C.

# Public areas must be kept at a constant temperature between 23˚C and 25˚C.

# Air extracted from the mortuary may not be used for energy recovery or recirculation.

 

# REFRIGERATION EQUIPMENT DESIGN AND INSTALLATION

# All heat- rejection equipment associated with refrigeration in the body- storage facilities must be located on the outside of the mortuary, in a well-ventilated space at the rear of the fridge(s). Compressors installed on top of body cabinets on the inside of the mortuary are not acceptable. Heat build-up within the mortuary, as a result of this type of arrangement, potentially leads to equipment failure.

# Regularly serviced refrigeration equipment components should not be situated within the confines of the mortuary. Refrigeration technicians should not be required to climb onto or over a body cabinet to carry out any maintenance work. It is preferable to have refrigeration equipment situated in a separate ventilated area to the rear of the body cabinets. The designer is to refer to the selected heat- rejection equipment’s installation manual to determine free space and ventilation openings required around this equipment, since these details can vary between system types.

# Gauges indicating the temperature within the body cabinet must be clearly visible above the door of the unit in order that this can be readily monitored.

# The acceptable average temperature within a normal body cabinet or refrigerated room is between 2.0˚C and 6˚C. In instances where a body has to be kept for an extended period of time a cabinet temperature of at least -20˚C is required.

# In facilities where large quantities of bodies are kept, cold rooms for the storage of multiple bodies on trays are recommended.

# The materials used for the construction of the units are to be of stainless steel to facilitate cleaning and long-term maintenance of the equipment. Grade 316 stainless steel (18/10) is preferable over Grade 304 (18/8), as it offers better corrosion resistance'''.'''

# For welded stainless steel construction, Grade 316L or similar is required.

# If a facility is required to collect and retain forensic samples, refrigeration equipment should be provided for the preservation of these samples. Preferably this equipment should be placed in an area where <s>they</s> it can readily be secured from unauthorised access and tampering.

 

# SECURITY ARRANGEMENTS

# Due to the medical and legal nature of the contents of a mortuary, it is essential that a mortuary has good access control and security systems.

# Theft from mortuaries should be forestalled by, inter alia, constantly monitoring all entrances and preventing free access to mortuary areas. This is especially important for the body- storage areas. Access card or tag systems are open to misuse and are not an appropriate access- control measure. Combinations of tag and biometric access- control systems are recommended.

# Door closers with a “hold-open” mechanism should be installed on the mortuary room doors. This enables doors to close automatically with normal traffic, but can also be held open when moving equipment or trolleys through. “Crash”- type doors should be avoided as these are not easily cleanable and are subject to damage and abuse.

# It is recommended that a timed alarm be fitted to doors to ensure that they are closed shortly after any entrance or exit. This is to <s>mitigate</s> militate against the tendency of keeping doors open with some form of door stopper.

# Body cabinets are to be fitted with locks to prevent the unauthorised opening of these units to forestall the theft of any personal items of the deceased.

# In instances where historical problems relating to unauthorized entry into mortuaries is evident, it is recommended that closed-circuit TV systems be installed to help in monitoring and securing the facility.

PART C – Operation

# OBJECTIVES

The project planning, design, construction and commissioning should aim to provide:

# a safe, secure and functional environment for visitors and staff;

# low capital and ongoing operating costs (service, staffing and maintenance);

# an environmentally appropriate design solution; and

# a fully accessible, inclusive environment.

 

# HEALTH AND SAFETY

In light of the above it is essential that every effort be made to ensure that personnel working in the mortuary are provided with all required personal protective equipment (PPE), as this is essentially an area where pathogens could be present and present a health risk to staff. The following items should be available to staff as a minimum:

# Rubber aprons (or similar impervious material)

# Latex gloves (or similar impervious material)

# Mesh gloves in facilities where post mortems are performed

# Disposable gowns

# Safety glasses or full-face visors.

# Waterproof footwear

# Face masks

# Respirators with the appropriate filters must be available for use in high-risk situations.

# Storage space for PPE

No one should be permitted to enter the body storage and preparation areas without donning appropriate gowns and footwear.

# MAINTENANCE

When designing the facility, every effort must be made to limit the amount of maintenance that would be necessary to keep it in good condition. Seamless surfaces for walls and floors are critical, as this will reduce ongoing maintenance costs. The following minimum requirements should be complied with:

# Seamless floor coverings required

# Radiuses corners ??? required between floors and walls.

# No sharp corners on any work surfaces that could injure people working in the area.

# Ceilings to be readily cleanable.

# Work surfaces are to be impervious to liquids and resistant to staining and corrosion.

# Refer to the room- requirement sheets herein and the IUSS Materials and Finishes guidance documents for further information on the general requirements for materials and finishes.

# All equipment requiring calibration, such as fridges and scales, are to be attended to on an annual basis or when it is suspected that they are defective in respect of their expected/intended performance

PART D – User Room Requirements

Room-requirement sheets

Table 3: Accommodation schedule
{| class="wikitable"
|'''Room Name'''
|'''Service Description'''
 
|'''Area'''

'''(m²)'''
|'''Min. Ceiling Height'''

'''(m)'''
|'''Occupancy'''

'''(Persons)'''
|'''Nominal Utilisation per day'''

'''(hours)'''
|-
|Ablution areas
|Ablution areas – male and female

One WHB per WC or urinal
|3 (per cubicle)
|2.8
|1
|4
|-
|Shower facilities
|Shower facilities – male and female
|3 (per cubicle)
|2.8
|1
|2
|-
|Changing room
|Staff changing room - lockers to be provided
|8
|2.8
|2
|2
|-
|Storage space
|Equipment and PPE storage space
 
|8
|2.8
|1
|1
|-
|Offices
|Office space – interview, body receiving, pathologist
|9
|2.8
|2
|8
|-
|Body/bier room
|Area where a body can be laid out for viewing and identification
|9
|2.8
|1
|8
|-
|Viewing room
|Viewing room – external to body- layout area
|9
|2.8
|4
|1
|-
|Autopsy room
|Autopsy facility – Autopsy table with water supply and discharge and extraction ventilation. WHBs and stainless steel working surfaces
|27
|2.8
|3
|3
|}

'''Table 4: Room services sheet'''
 
{| class="wikitable"
|'''Room Name'''
|'''Temp'''

'''(°C)'''
|'''Ventilation'''

'''(AC/h)'''
|'''Ventilation'''

'''Type'''
|'''Pressure Relative to'''

'''Ambient'''
|'''Wet Services'''
|'''SSO'''

'''400V'''
|'''SSO'''

'''230V'''
|'''Task Illuminance'''

'''(lux)'''
|'''Data Points'''
|'''Colour Rendering'''

'''(Ra)'''
|-
|Reception area
|22-25°C
|2
|Forced supply
|=
|
|0
|0
|100 at floor level
|0
|80
|-
|Visitors ablution areas
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|WC,

WHB
|0
|0
|150 at floor level
|0
|80
|-
|Public waiting area
|22-25°C
|2
|Forced supply
|<nowiki>+ </nowiki>
|
|0
|0
|100 at floor level
|0
|80
|-
|Offices
|22-25°C
|2
|Forced supply/ recirc.
|=
|
|0
|2
|300 at desk level
|1
|80
|-
|Circulation Spaces
|22-25°C
|10
|Forced supply/ recirc.
|=
|
|0
|0
|200 at floor level
|0
|80
|-
|Viewing room
|22-25°C
|2
|Forced supply
|<nowiki>+ </nowiki>
|
|0
|0
|100 at floor level
|0
|80
|-
|Layout room
|20-21°C
|2
|Forced extraction
|<nowiki>- </nowiki>
|WHB
|0
|0
|300 at table level
|1
|80
|-
|Storage space
|22-25°C
|4
|Forced supply
|=
|
|0
|1
|200 at floor level
|0
|80
|-
|Mortuary
|20-21°C
|12
|Forced extraction
|<nowiki>- </nowiki>
|WHB,

FD
|0
|1
|200 at floor level
|0
|80
|-
|Mortuary plant area
|n/a
|n/a
|Natural ventilation
|=
|
|1
|1
|150 at floor level
|0
|80
|-
|Autopsy table
|20-21°C
|20
|Forced extraction
|<nowiki>- </nowiki>
|CW Faucet
|0
|1
|5200 at table level
|0
|90
|-
|Autopsy room
|20-21°C
|20
|Forced extraction
|<nowiki>- </nowiki>
|WHBs,

FD
|0
|2
|500 at floor level
|1
|90
|-
|Changing room
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|WHB
|0
|1
|150 at floor level
|0
|80
|-
|Staff ablution areas
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|WHB,

WC
|0
|0
|150 at floor level
|0
|80
|-
|Shower facilities
|22-25°C
|15
|Forced extraction
|<nowiki>- </nowiki>
|CW + HW

Faucet
|0
|0
|150 at floor level
|0
|80
|}

'''Table 5: Room finishes'''
 
{| class="wikitable"
|'''Room Name'''
|'''Floor'''

'''Material'''
|'''Wall / Floor Interface'''
|'''Walls'''

'''Finish'''
|'''Ceiling'''

'''Finish'''
|'''Glazing'''

'''Type'''
|'''WHB'''
|'''Doors'''

'''Type'''
|-
|Ablution areas (all)
|Jointless vinyl sheet
|Skirting coved and finished as per floor
|Ceramic wall tiles with epoxy grout
|Washable acrylic paint
|Obscure laminate safety glass
|1 per WC or urinal
|Solid wood with galvanised steel or stainless steel sheet trolley plates
|-
|Public waiting area
|Jointless vinyl sheet
|Coved vinyl skirting
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Lockable glazed entrance door
|-
|Changing room
|Jointless vinyl sheet
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Obscure laminate safety glass
|0
|Solid wood with galvanised steel or stainless steel sheet trolley plates
|-
|Storage space
|Jointless vinyl sheet
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood with galvanised steel or stainless steel sheet cladding
|-
|Offices
|Jointless vinyl sheet
|Coved vinyl skirting
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood
|-
|Body Room
|Self- levelling epoxy
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood
|-
|Viewing Room
|Self- levelling epoxy
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|Solid wood
|-
|Autopsy Room
|Self- levelling epoxy
|Skirting coved and finished as per floor
|Washable acrylic paint
|Washable acrylic paint
|Obscure laminate safety glass
|Min 1 per autopsy table
|Solid wood with galvanised steel or stainless steel sheet cladding
|-
|Circulation Spaces
|Jointless vinyl sheet
|Coved vinyl skirting
|Washable acrylic paint
|Washable acrylic paint
|Clear laminate safety glass
|0
|
|}
'''PART E – Examples and case studies''' {{Expand}}
[[Category:Procurement and Operation]]

Sustainability

2021-05-05T05:54:37Z

Tmojanaga: /* REFERENCES */

==INTRODUCTION==

==Purpose==
This document has been developed for the Department of Health to ensure that sustainable development is integrated into to planning and design of health facilities. The document defines sustainable development and outlines the implications of this for the built environment. It provides objectives and criteria that can be used in the development health facilities in South Africa.

==Background==
The Department of Health wish to support sustainable development in South Africa and ensure that there is an appropriate balance between economic development, social integration and protection of the environment.
Global Warming and South African legislation and policy now make it imperative that built environment projects address sustainability. However, there is limited South African guidance on how sustainable development can be integrated with built environment projects. There is also the perception that addressing sustainability in facilities will be expensive and complicated.
This document provides guidance and checklists that can be used to support the integration of sustainability into health facilities. It shows that by addressing sustainability early in projects, additional costs can be minimised and innovative, high-performance solutions that benefit society, the economy and the environment can be achieved. It also shows that achieving more sustainable facilities need not be complex but can be based on robust, sensible and simple measures.

==How to use this document==

This document provides a framework that can be used to inform the development of health facilities. It can be used in the following ways:

*'''Awareness''': This document can be used to increase awareness about sustainable development and the need to address this in built environment projects. This will lead to more rigorous debate on development options and support more innovative and sustainable solutions.

*'''Setting sustainable development targets''': This framework can be used by a development team to set explicit and challenging sustainable development targets for projects. This is done by setting quantified targets against criteria in the document and putting in place systems to ensure that these are achieved.

*'''Self-assessments''': This framework can also be used for self-assessment and to ascertain the performance of development proposals. To carry this out refer to the Facility Recommended Compliance sheet and Compliance Checklist at the end of the document. This enables different health facility development proposals to be evaluated in terms of recommended compliance. Assessment using the criteria can also inform the design process by being used to evaluate different development options. This enables optimal solutions to be developed in an iterative and efficient way.

*'''Coordinated development''': Some criteria in the document may appear not to be in the remit of, or possible in, a single development. These criteria however can be achieved through partnerships and local collaboration. This framework can be used bring together the key role players in order to develop integrated plans that enable key sustainable development objectives to be achieved.

==Structure of the guideline==
The document has the following structure:

*'''Implementing Sustainable Development''': This section provides a description of sustainable development and translates this into specific sustainable development objectives for the built environment.

*'''Built Environment Sustainable Development Objectives''': In this section more detailed guidance and checklists are provided for each of sustainable development objectives listed in the section above.

*'''Sustainability Integration Plans''': This provides guidance on plans and a structure that can be used to integrated sustainability in design and operational processes.

==IMPLEMENTING SUSTAINABLE DEVELOPMENT==

===Introduction===
South Africa faces a range of social, economic and environmental challenges. HIV/AIDs has resulted in a life expectancy dropping from 67 years in 1998 years to around 47 years currently. Unemployment is estimated to be 27% and climate change is likely to lead to increasing water stress, reduced food security and loss of species and ecosystems (DEAT 2009).
Sustainable development, which aims to achieve social and economic improvements while reducing negative environmental impacts, can be used to address these challenges. Sustainable development however can be difficult to achieve. This is because a holistic and integrated approach is required and the development sector and in particular, the construction industry, operates in a highly fragmented way. In addition, the concept of sustainable development is still new and has not been adequately translated into practical actions that can be readily implemented.
This section defines sustainable development and translates this into key built environment objectives. It also describes the role of the built environment in creating environmental and other problems and shows how integrating sustainable development considerations into construction and the built environment can make a substantial contribution to improving the social, economic and environmental performance of the built environment.

===The environmental context===
Increasing carbon emissions from human activities and a reduction in the ability of the natural environment to absorb carbon dioxide is leading to an accumulation of greenhouse gases in the upper atmosphere. These gases trap more heat in the upper atmosphere leading to global warming and temperatures are predicted to increase by 2 - 6°C OC by the end of the century (IPCC, 2007). Estimates carried out for the City of Joburg indicate that temperatures in the next 50 years may increase between 2 and 3.5°C (Hewitson, Engelbrecht, Tadross, Jack, 2005).

Within Africa, South Africa produces the highest CO2 emissions and has one of the highest CO2 emissions per GDP in the world. In 2002, carbon emissions per capita in South Africa were 8.4tonnes/capita - higher than Western European averages of 7.9tonnes/capita (SEA 2006).
Global warming is likely to impact Africa particularly negatively. The National Climate Change Response Policy Developed by the Department of Environment and Tourism outlines the following impacts (DEAT 2009a):

*Agricultural production and food security in many African countries are likely to be severely compromised by climate change and variability. Projected yields in some countries may be reduced by as much as 50% in some countries by 2020 and as much as 100% by 2100. Small scale farmers will be most severely affected.

*Existing water stresses will be aggravated. About 25% o Africa’s population (about 200million people) currently experience high water stress. This is projected to increase to between 75-250 million by 2020 and 350-600 million by 2050.

*Changes in ecosystems are already being detected and the proportion of arid and semi-arid lands in Africa is likely to increase by 5-8% by 2080. It is projected that between 25 and 40% of mammal species in national parks in sub-Saharan Africa will become endangered.

*Projected sea-level rises will have implications for human health and the physical vulnerability of coastal cities. The cost of adaptation to sea level rise could amount to 5-10% of gross domestic product.

*Human health will be negatively affected by climate change and vulnerability and incidences of Malaria, Dengue fever, Meningitis and Cholera may increase.

===The contribution of the built environment===
Construction and the built environment make a substantial contribution to global warming and play a significant role most economies. Environmental, social and economic impacts attributed to the built environment at a global scale are outlined below.

*Consumes 40% of energy use,

*Consumes 17% of fresh water use,

*Consumes 25% of wood harvested,

*Consumes 40% of material use,
*Employs 10% of the world’s work force,

*Construction is the largest employer of micro-firms (less than 10 people),

*Facilities are typically located on the most productive land (Estimated to be 250 million hectares world wide, mostly on primary agricultural land).

In South Africa the built environment is directly responsible, through electricity consumption, for over 23% of South Africa’s carbon emissions (see table below). Vehicle-based infrastructure and transport planning has resulted in transport contributing to 16% of South Africa’s CO2 emissions and an additional 18mtCO2 per year, or about 4% of South Africa’s CO2 emissions, come from the manufacture of building materials (CIDB 2009).

Sector C02 Emissions

Commercial 10%

Residential 13%

Transport 16%

Industry 40%

Mining 11%

Other 10%

Total 100%

''Figure 1: South African carbon emissions per sector''

===Defining sustainability===
Recent work by the World Wildlife Fund contributes substantially to defining sustainable development by providing quantified minimum criteria for sustainability. In the 2006 Living Planet Report, sustainability is defined as achieving an Ecological Footprint (EF) of less than 1.8 global hectares per person and an Human Development Index (HDI) value of above 0.8 (WWF 2006).

===Ecological Footprint===
An Ecological Footprint is an estimate of the amount of biologically productive land and sea required to provide the resources a human population consumes and absorb the corresponding waste. These estimates are based on the consumption of resources and production of waste and emissions in the following areas:

*Food, measured in type and amount of food consumed,

*Shelter, measured in size, utilization and energy consumption,

*Mobility, measured in type of transport used and distances travelled,

*Goods, measured in type and quantity consumed.

*Services, measured in type and quantity consumed The area of biologically productive land and sea for each of these areas is calculated in global hectares (gha) and then added together to provide an overall ecological footprint. This measure is particularly useful as it enables the impact of infrastructure and lifestyles to be measured in relation to the earth’s carrying capacity of 1.8 global hectares (gha) per person.

===The Human Development Index===
The Human Development Index was developed as an alternative to economic progress indicators and aimed to provide a broader measure that defined human development as a process of enlarging people’s choices and enhancing human capabilities (United Nations Development Programme 2007). The measure is based on:

*A long healthy life, measured by life expectancy at birth,

*Knowledge, measured by the adult literacy rate and combined primary, secondary, and tertiary gross enrolment ratio,

*A decent standard of living, as measure by the GDP per capita in purchasing power parity (PPP) in terms of US dollars.

===South African EF and HDI figures===
The figures below show that South Africa has an ecological footprint of 2.1, above the maximum required of 1.8 gha and a human development index measure of 0.66, below the minimum of 0.8 required for sustainability.

Measure South Africa Sustainability Target
Ecological Footprint (gha) 2.1 1.8
Human Development Index 0.658 0.8
{| class="wikitable"
|+
!Measure
!South Africa
!Sustainability Target
|-
|Ecological Footprint (gha)
|2.1
|1.8
|-
|Human Development Index
|0.658
|0.8
|}

For South Africa to move towards sustainability there must therefore be an improvement in both the Ecological Footprint and Human Development Index performance. The built environment has a key role in supporting this improvement.

===The legislative and policy context===
South Africa has a range of legislation and policy that aims to protect the environment and support sustainable development. Key legislation supporting sustainable development includes the South African Constitution and the National Environmental Management. These are discussed briefly below.

===South African Constitution===
The South African Constitution contains a Bill of Rights that enshrines the rights of all people in South African and affirms the democratic values of human dignity, equality and freedom. The Bill has sections covering equality, human dignity, privacy, freedom of religious belief and opinion, environment, property, housing, healthcare, food, water and social security, children, education, language and culture. Through a section on equality, the Bill requires that all people have full and equal enjoyment of these rights and freedoms:

''Everyone is equal before the law and has the right to equal protection and benefit of the law.''

Equality includes the full and equal enjoyment of all rights and freedoms. To promote the achievement of equality, legislative and other measures designed to protect or advance persons or categories of persons, disadvantaged by unfair discrimination, may be taken.
Environmental rights in the Bill of Rights include the right to an environment that supports health and wellbeing. It also requires legislation to be developed to ensure that the environment is protected and that development that does occur is both sustainable, and justifiable:

===Environment===
Everyone has the right

a). to an environment that is not harmful to their health or well-being; and

b). to have the environment protected, for the benefit of present and future generations, through reasonable legislative and other measures that ¬

#prevent pollution and ecological degradation;
#promote conservation; and
#secure ecologically sustainable development and use of natural resources while promoting justifiable economic and social development.

Sustainable development and the protection of the environment is, therefore, a constitutional obligation and there is a requirement for ‘reasonable legislative and other measures’ to be put in place to ensure that this achieved. '''This document represents a measure taken by the Department of Health to achieve sustainable development.'''

===Carbon emission mitigation strategies===
South Africa is a signatory to both the United Nations Framework Convention on Climate Change (UNFCC) and the Kyoto Protocol. In order to address UNFCC commitments, the Long Term Mitigation Scenarios (LTMS) process was initiated in 2006 and completed in 2008. This formulated strategies to ensure that South Africa would reduce carbon emissions. Many of the mitigation strategies identified have implications on the built environment and these are outlined below (DEAT 2009b):

*Limits on less efficient vehicles

*Passenger modal shift
*Solar water heater subsidy

*Commercial efficiency
*Residential efficiency

*Renewables with learning

*Waste management

*Land use: afforestation

*Escalating CO2 tax

Following the LTMS process, key policy approaches were agreed on by the South African cabinet. These strengthen current energy efficiency and demand-side management initiatives such as environmental fiscal reform and carbon taxation which will penalize energy inefficient technology and provide for additional tax allowances of up to 15% for energy-efficient equipment.
The LTMS process however also showed that although significant emission reductions could be achieved through technology-based actions, these were not sufficient for the scale of change required and that adaptations in social behaviour would be required. (DEAT 2009c).The LTMS, therefore, proposed a number of people and building orientated measures that offered low-cost large scale mitigation impacts including:

*Social adaptation and changes in human habitation, urban planning and the built environmental

*Studies on the distance between work, home and other life functions

*Modal shifts to public transport and moves away from individual car owners towards the operation of shared vehicles

*Food production and consumption, as well as the localization of these activities

==Built environment sustainable development objectives==
The environmental context, legislation and potential future measures to reduce carbon measures make it clear that the built environment must change to support sustainable development. It also makes it clear that many of the conventional practices in the planning, design, construction and management of building must be substituted with improved more sustainable approaches.
In order to develop practical measures that can be integrated into the built environment, it is useful to set out built environment or development objectives that, together, would support sustainable development. These objectives are outlined below and form the starting point for the next sections of this document where more detailed criteria are provided.

===Environmental objectives===

*Energy: The building is energy efficient and uses renewable energy

*Water: The building minimises the consumption of mains potable water.

*Waste: The building minimizes emissions and waste directed to landfill

*Materials: Construction impacts of building are minimized
*Biodiversity: The building supports biodiversity

===Economic objectives===

*Transport: The building supports energy efficient transportation
*Resource Use: The building makes efficient use of resources
*Management: The building is managed to support sustainability
*Local Economy: The building supports the local economy
*Products and Services: The building supports use of more sustainable products and services

===Social objectives===

*Access: The building supports access to facilities

*Health: The building supports a healthy and productive environment

*Education: The building supports education
*Inclusion: The building is inclusive of diversity in population

*Social Cohesion: The building supports social cohesion

===Integrating sustainable development objectives into health facilities===
Integrating sustainable development objectives requires structured processes. These are described below in terms of design and operational processes.

===Design processes===
Addressing sustainability in designs for new health facilities can be achieved through the following steps:

'''Target setting:''' Challenging sustainability targets should be set for the building and agreed with all of the key stakeholders of the project including the design team, the facilities manager and the funder or owner of the building. Targets should take into account government policy and strategies as well as local and international best practice.

2. '''Design principles:''' Strategies and design principles required to achieve these sustainability objectives should be understood and established from the outset. For instance, energy targets may require passive environmental control strategies to be well understood and established from the outset. These strategies and their implications can be understood through analysis of best practice examples and precedents.

3. '''Integrated design:''' Once targets and design principles have been established, an integrated design process should be used to ensure that all aspects of the building work together to achieve the required performance. This requires the different disciplines to work closely together.

4. '''Testing:''' Throughout the design process, checks should be carried out to ensure that targets set will be achieved. This can be done through calculations, modelling and analysis which assesses performance against targets set. Where aspects of the design are found not to meet targets a re-evaluation of the design should be carried out and in an iterative and integrated way, improved, to ensure that performance achieves, or surpasses, targets set.

5. '''Detailed design and implementation:''' It is important to ensure that the principles set out in 2 above, are carried out in to detail otherwise this may affect operational performance. This includes, for instance, details such as appropriate locations for switches, labels and instructions.

6. '''Handover:''' On completion, effective processes should be followed to ensure that design intentions are carried through into building operation. This includes effective commissioning, handover and training processes which ensure that designers, subcontractors and suppliers transfer knowledge and skills to facilities managers required to ensure effective management of the building.

===Operational performance===
Addressing sustainability in existing or newly developed health facilities can be achieved through the following steps:

#'''Data''': Obtain operational performance data on your building for at least a full year. For energy, this can be obtained in the form of utility statements that indicate energy consumption in kWh.
#'''Benchmark''': The above data should be normalised so that it can be compared to benchmarks. This will indicate whether your facility is below or above benchmark performance. If performance is well over benchmark, further investigation should be carried out, as this indicates there is room for improvement.
#'''Walkthrough assessment''': A walkthrough energy assessment can be used to identify where obvious improvements can be made. Checklists are used as a basis for these assessment and they can be carried out by health facilities personnel with training or experience of the respective areas such as water and energy.
#'''Audit''': Where walkthrough assessments and benchmarking exercise indicate that a full audit is warranted this can be carried out. These audits provide detailed reports on interventions that can be carried out to improve sustainability performance in a facility.
#'''On-going operational performance''': A key component of improving sustainability operational performance, in combination with the steps above, is an on-going programme that improves performance. This includes detailed sustainability monitoring and reporting as well as day-to-day management processes required to optimise performance. Operational performance should be allocated to an individual who is required to report on this to senior management. Identified responsible persons should be provided with appropriate training, resources and incentives to achieve excellent energy performance.

==='''Sustainability integration plans'''===
The above processes can be supported through sustainability integration plans which present targets, strategies and monitoring process for each sustainability performance areas. The simplest form of this is illustrated in the table below and can be used for both design and operational processes.

Area Targets Strategy Monitoring
Sustainability performance area Sustainability targets and requirements Proposed strategy and processes Progress on achievement of targets
{| class="wikitable"
|+
!Area
!Targets
!Strategy
!Monitoring
|-
|Sustainability performance area
|Sustainability targets and requirements
|Proposed strategy and processes
|Progress on achievement of targets
|-
|
|
|
|
|-
|
|
|
|
|}



==ENERGY==

===Objective===
The building is energy efficient and uses renewable energy

===Introduction===
Energy is used in health facilities to operate equipment, heat water, and to ensure that required minimum lighting, ventilation and thermal comfort standards are met. In most existing South African building it is estimated that savings of up to 30% of energy consumption can be achieved at no or low cost. These savings can be considerably higher in new facilities were passive strategies, energy efficient equipment and renewable energy systems can be used.

Ensuring that health facilities are more energy efficient use renewable energy has a wide range of benefits including:

*Reduced carbon emissions and therefore global warming impacts

*Reduced impact of mains power outages

*Reduced negative health impacts of pollution from coal-fired power stations

*Reduced operational costs

*Improved internal environment where passive strategies such as day lighting and natural ventilation lead to improved internal conditions relative to mechanical ventilation and artificial lighting.

===Energy consumption in health facilities===
Energy in South African health facilities is largely sourced from electricity, however gas and coal may also be used in larger hospitals and some rural clinics rely on local renewable energy systems such as photovoltaic panels and solar water heaters. The proportions of energy use in a conventional South African hospital and clinic are shown in the pie charts below:
{| class="wikitable"
|+
!
!
|-
|Proportions of energy consumption in a typical South African hospital
|Proportions of energy consumption in a typical South African clinic
|}

Data on energy consumption and demand in South African facilities is not readily available. However the following table provides a number of benchmarks 1
{| class="wikitable"
|+
!Energy benchmark type
!Typical
!Good practice
|-
|Clinics
|
|
|-
|Energy consumption (kWh/m2.a)
|1
|1
|-
|Maximum demand (VA/m2)
|1
|
|-
|Renewable energy (kWh/m2.a)
|0
|
|-
|Hospitals
|
|
|-
|Energy consumption (kWh/m2.a)
|395 2
|1
|-
|Maximum demand (VA/m2)
|1
|
|-
|Renewable energy (kWh/m2.a)
|0
|
|}
 
===Design Criteria===
Highly energy efficient facilities are optimized and integrated solutions that respond closely to the local site, climate and required internal functions. It is therefore difficult to prescribe this in a set of specific design criteria; however a series of questions are outlined below which can be used to check that key energy considerations have been addressed.

===Design and operation===
Improving energy performance in health facilities requires plans, procedures and processes that ensure that sustainability is integrated effectively into design and operations of a health facility. This can be achieved through setting challenging targets and effective monitoring processes.

#Have challenging sustainability targets been set for energy?
#Have effective procedures been established to model and test performance throughout the design process to ensure that these targets are achieved?
#Have the effective monitoring and evaluation systems, including regular reporting to the client, been put in place to ensure targets are achieved?
#Have capacity and systems in the form of staffing, training, manuals, commissioning and monitoring processes been planned for and put in place to ensure that design targets are achieved in operation.

===Orientation===
Orienting facilities so that the long facades face North – South helps to reduce unwanted heat gains from low angle sunlight early in the morning and late in afternoon. Where there is no alternative but to have facades face East and West, appropriate solar shading should be provided to avoid glare and control solar heat gain.

1. Are the long facades of facilities orientated to face within 15 degrees of a North – South orientation?

2. Is glazing on West and East facades minimized?

===Building shape===
While building shape and form may generally be determined by the functions accommodated, building form can also be shaped to minimise energy consumption. Shaping built form to limit building depth (see below) ensures that interior spaces can be naturally ventilated and day lit. Built form can also direct prevailing breezes through the facilities, supporting cooling and ventilation. It can also be used to create comfortable external spaces.

#Does the form of the building respond to local climate and topography?
#Does the building shape support reduced energy consumption and help create comfortable internal and external spaces?

===Building depth===
Limiting building depth enables internal space to be day lit and naturally ventilated. This ensures that internal space may not need artificial lighting or mechanical ventilation for much of the day, reducing energy consumption.

#Are building depths less than 15m?

==='''Insulation'''===
Insulation, especially when combined with thermal mass can be used to maintain comfortable indoor conditions without significant use of mechanical equipment. Insulation can ensure that valuable heat gains from people, equipment and the sun can be retained in the building to support comfort during winter. It can also reduce unwanted heat gains from ambient conditions in summer.

#Do the building envelope U-values achieve or surpass minimum values outlined in SANS 204 (SABS 2008)?

==='''Solar shading and glazing'''===
Glazing is usually the most vulnerable area of a building envelope and high heat losses and gains can be experienced through this component. It is therefore important to design glazing and devices which enable light and heat flow to be controlled.

#Is the glazing to wall ratio compliant with SANS 204 (SABS 2008)?
#Is solar shading compliant with SANS 204 (SABS 2008)?
#Has glazing with appropriate U-values, visual transmittance and solar heat gain coefficients been selected?

===Opening areas===
Opening areas within the building envelope such as doors and windows can be used to naturally ventilate the building. In general, it is advisable to provide for openings even in facilities that are mechanically ventilated and cooled as this enables them to be occupied and used in the event of a power cut.

#Are opening areas located to support effective natural ventilation?
#Is the area of openings provided compliant with SANS 10400 XA:2011?

Air tightness

Uncontrolled infiltration and airflow through the building envelope can affect comfort and increase heating and cooling loads in the building.

#Has careful detailing and specification been used to minimise infiltration in the building.
#Has a plan for rigorous construction supervision been put in place to ensure that building envelopes are air tight?

===Mechanical systems===
As far as possible mechanical cooling, heating and ventilation should be avoided. If this is not possible, a mixed mode operation should be selected. Mixed mode operation use mechanical system when ambient and internal conditions require this, but otherwise rely on passive systems to maintain thermal comfort and meet ventilation rate requirements. In particular circumstances mechanical cooling, heating and ventilation may be required for much of the year.

#Can the building or most of the spaces be passively cooled, heated and ventilated without the requirement for mechanical systems?
#If the application of passive systems will not achieve an acceptable number of annual comfort hours, can complementary mechanical systems be introduced to meet the comfort and ventilation requirements?
#Where zones exist within a facility that are not tolerant of passive ventilation and comfort systems, can a zoned mixed mode ventilation strategy be adopted?
#Where mechanical systems have been used has a rigorous exercise been undertaken to identify the most appropriate and energy efficient system?
#Where mechanical systems have been used do these include features that help reduce energy consumption such as:

a. An economy cycle

b. Controls that enable easy systems adjustments in order to benefit for seasonal and occupancy changes.

===Equipment===
As equipment used in building can consume large amounts of energy, the energy efficiency of equipment and energy ratings should be a key consideration. In addition, controls that ensure equipment is switched off when not in use should be specified.

#Is energy efficiency a key consideration in the selection of equipment?
#Is benchmarking energy consumption or energy rating used to support the selection of equipment?
#Are the controls provided for equipment easy to use and do they ensure that equipment is off when not required?

===Internal lighting===
Ensuring adequate lighting levels may be a key consideration in many spaces within health building. This should however be achieved in the most energy efficient way. Lighting is rapidly becoming more energy efficient and there are increasingly sophisticated controls.

#Is energy efficiency a key consideration in the selection of lighting?
#Has a rigorous evaluation process, including lighting power density calculations, been undertaken to ensure that the selected lighting system is highly energy efficient?
#Have appropriately sized lighting zones (ie under 100m2) been designed to avoid lighting being on where it is not required.
#Are lighting switching arrangements easy to use and encourage users to switch off lighting when not required?
#Are motion sensors used to switch lighting off in areas such as store rooms and meeting rooms when these are not used?
#Are daylight sensors used to switch lighting off in areas where these is adequate daylight? Areas with good daylight are usually found within a zone of about 6 m from external windows.
#Can light harvesting techniques and systems be incorporated in the design solution?

===External lighting===
Concerns about security often result in highly lit external areas. While security and building access requirements must be met, external lighting should be designed to be as energy efficient as possible.

#Are only areas that specifically require external lighting included?
#Has external lighting been provided as close to the area that requires lighting as possible and directed in order to avoid losses and light pollution?
#Are photo sensors, motion sensors or timers used to ensure that lighting is only on when required?

===BMS system===
Building Management Systems (BMS) should be used in complex building with complex equipment and systems. A BMS enables different systems to integrated and controlled and can support energy efficiency

#Has a BMS been used to coordinate and integrate systems, where complex systems are used in a large building?
#Is the BMS easy to use and understand?
#Is there local training and support for the BMS>
#Is the BMS system developed to open protocols and standards?
#Does the BMS include features that support energy efficiency such as:

a. Easy access to equipment schedules so that these can easily be changed to suite occupancy patterns.

b. Reminders to ensure that BMS operator tune building systems for greatest energy efficiency. For instance the system may provide a reminder to change air conditioning set points to match seasonal changes.

c. Reporting on water and energy sub metering and related equipment schedules.

===Sub metering===
An appropriate sub-metering system enables effective energy management. A facilities manager can see how much energy is used in different areas or uses in the facility. Sub-meters also show when and how energy is used through for instance energy profiles which show energy consumption and demand over time.

#Has an energy sub metering design been developed that will monitor all of the main energy uses in the facility?
#Is energy management data provided in formats and reports that can be easily understood and analyzed to support improved energy management?
#Does the system provide energy management report that can be used by both facilities managers and senior managers to improve energy efficiency in the facility?

===Renewable energy===
Increasingly renewable energy is becoming a competitive alterative to ESKOM supplied power. It also has the advantage that it increases the energy autonomy and independence of facilities, allowing these to operate even when there are mains power cuts.

#Are solar water heaters used to heat water in the facility?
#In areas with high quality, reliable sunlight, are photovoltaic systems used to reduce the reliance on ESKOM power?
#In areas with high quality, reliable wind, are wind turbines used to supplement to reduce the reliance on ESKOM power?

==WATER==

===Objective===
The building minimises the consumption of mains potable water.

===Introduction===
Water is used in health facilities for cleaning equipment, utensils and facilities, laundry, irrigation, food preparation and for drinking. In most existing South African health facility it is possible to reduce mains potable water consumption at no or low cost. These savings can be considerably higher in new facilities where water efficient technologies, grey water and rainwater systems can be used.

Ensuring that health facilities are more water efficient has a wide range of benefits including:

*Reduced water consumption and associated negative environmental impacts
*Reduced impact of mains water shortages or outages
*Reduced operational costs

===Water consumption in health facilities===
Water in South African health facilities is largely sourced from municipal potable water supply, however in some areas water may come from a rain water tanks or a borehole. The proportions of water use in a conventional South African hospital and clinic are shown in the pie charts below:
{| class="wikitable"
|+
!
!
|-
|Proportions of water consumption in a typical South African hospital
|Proportions of water consumption in a typical South African clinic
|}



Data on energy consumption and demand in South African facilities is not readily available. However the following table provides a number of benchmarks 1
{| class="wikitable"
|+
!Water benchmark type
!Typical
!Good practice
|-
|Clinics
|
|
|-
|Water consumption (kl/m2.a)
|1
|1
|-
|Hospitals
|
|
|-
|Water consumption (kl/m2.a)
|70 2
|1
|}
 

===Criteria===
The consumption of mains potable water in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective performance requirements within the health facility; however a series of questions can be used to check that key water considerations have been addressed. These are outlined below.

===Wash Hand Basin Taps===
Controlling and reducing water flows in wash hand basin taps can be used to reduce water consumption.

#Are wash-hand basin tap flow rates should not exceed 6L/minutes?
#Are passive infra-red (PIRs) or push-button controls used to limit the duration of flows?
#Has legionella control been considered when designing for low flow and systems and where existing system are made redundant?

===Toilets===
Reducing flush rates in water-borne sanitation can be used to reduce water consumption.

#Have WC flush rates been specified that do not exceed 6L/flush?
#Have dual flush controls can be used to ensure that reduced flush rates can be used when full flushes are not required?

===Showerheads===
Controlling and reducing water flows in showers can be used to reduce water consumption. The following measures can be considered:

#Have shower head flow rates been specified to not exceed 10L/minute?
#Are push-button type controls used to limit the duration of flows?
#Has legionella control been considered when designing for low flow and systems and where existing system are made redundant?

===Irrigation===
Minimizing irrigation water requirements can be used to reduce water consumption. The following measures can be considered:

#Are locally indigenous species (species found in the local area) used to minimise irrigation requirements?
#If irrigation is required, are highly efficient water delivery systems, such as a drip irrigation linked to soil moisture probes, used to minimise irrigation requirements.
#Has grey water been used to avoid the use of potable water for irrigation?

===Grey water systems===
Grey water systems reduce mains potable water consumption by reusing lower quality water within the facility. Examples of this are where waste water from showers and wash hand basins is captured and reused to flush toilets. Other sources of grey water include waste water from laundries and HVAC systems. Grey water systems however are potentially hazardous to human health, particularly in health facility environments. In particular, grey water which is left to stand for over 36 hours or is contaminated by food or similar waste is considered as blackwater and requires the same treatment as sewage. Therefore, grey water systems should only be designed, implemented and operated by appropriately competent people. Potential grey water applications in health facility environments are described below:

*Wash hand basin and shower waste water: Waste water from wash hand basins and showers can be directed to a grey water system and then used to flush toilets or for landscape irrigation.
*Vehicle wash: Waste water from vehicle waste can be reused to wash vehicles for up to 3 or 4 times. After this it can be disposed of or used for irrigation.
*HVAC plant: It may be possible to use waste water from HVAC systems for irrigation or to flush toilets. To ascertain if this is possible investigations should be carried out with the HVAC manufacturer and grey water specialists.

The following considerations in relation to grey water systems should be made:

*Have significant sources of grey water from, for instance, showers and wash-hand basins, been captured in a grey water system?
*Are grey water usage points appropriately labelled to prevent unsafe consumption.
*Will this grey water be used for irrigation or to flush toilets in order to significantly reduce portable water consumption?
*Is the proposed grey water system easy and cost effective to maintain?
*Have as many of the potential health hazards associated with the system been eliminated?

===Rain water systems===
Rain water systems store water captured from roofs or hard landscape surfaces. This water is then available for irrigation, to flush toilets or for cleaning. In large facilities very substantial amounts of water can be captured and used to reduce mains potable water consumption. A number of different types of systems are described below:

*Roof rainwater harvesting: Rainwater from roofs is directed to tanks and stores. Usually a proportion of initial run-off is directed to waste as it may have picked up dust and other debris. This system is the most common and generally has the lowest cost as rainwater tanks can be installed above ground surface.
*Hard surface rain water: This system captures storm water run-off from hard surfaces such as game pitches, paths and car parking. This type of system generally requires some form of filtration to remove debris, and in the case of car parking, oil wastes. Tanks are usually sub-surface.
*Landscape surface run-off capture: Surface run-off from soft landscaping can be captured and reused. This is sometimes used as part of an onsite storm water retention strategy. The disadvantage of this system is that the resulting water quality can be poor as debris and silt may be picked up. The filtration and maintenance requirements are therefore more stringent.

The following considerations in relation to rain water systems should be made:

#Have significant sources of rain water from roof and hard surfaces been captured in a rainwater harvesting system?
#Will this rain water be used in functions such as irrigation or to flush toilets in order to significantly reduce portable water consumption?
#Is the proposed rainwater harvesting system easy and cost effective to maintain? Have as many of the potential health hazards associated with the system been eliminated?

==WASTE==

===Objective===
The building minimizes waste directed to landfills.

===Introduction===
Waste in South African health facilities is largely directed to landfill sites. Not only does this use up valuable land, but can also lead to air, soil and water pollution if not waste is not disposed of correctly. In addition, this waste also consists of valuable resources that could be easily reused and recycled. Recycling and reusing materials not only reduces energy and resource consumption but can also create jobs and additional revenue streams.

Ensuring that health facilities minimise waste and reuse and recycle waste products are as follows:

#Reduced loss of land area to landfill
#Reduced energy and resource consumption
#Potential to create jobs and small enterprises

===Waste production in health facilities===
Waste in South African health facilities is largely directed to landfill sites. However in some area waste may be disposed of by local recyclers. The proportions of waste generated use in a conventional South African hospital and clinic are shown in the pie charts below:
{| class="wikitable"
|+
!
!
|-
|Proportions of waste in a typical South African hospital
|Proportions of waste in a typical South African clinic
|}

Data on waste in South African facilities is not readily available. However the following table provides a number of benchmarks 1
{| class="wikitable"
|+
!Waste benchmark type
!Typical
!Good practice
|-
|Clinics
|
|
|-
|Waste production (kg/m2.a)
|1
|1
|-
|Proportion of waste recycled or reused
|10%
|
|-
|Hospitals
|
|
|-
|Waste production (kg/m2.a)
|1
|1
|-
|Proportion of waste recycled or reused
|10%
|
|}

===Criteria===
Waste in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that key waste considerations have been addressed. These are outlined below.

===Provision for recycling===
Recycling can be encouraged by developing systems that make this easy. This includes providing easy-to-use receptacles for different types of waste and providing space in the right locations so that waste can be stockpiled into worthwhile quantities for a recycler to collect.

#Are there appropriate waste receptacles at the waste source to enable waste to be disposed of easily?
#Are there adequate number and type of waste receptacles at source to ensure that the value of waste is not reduced as a result of wastage or mixing of waste? For instance, clean waste paper can be spoilt if mixed with food waste.
#Has adequate storage space been provided in an appropriate location for the different recycling waste streams so that this waste can be stockpiled and easily accessed recycling contractors?

===Engagement with local recyclers===
Engaging with local recyclers earlier in the development of a new or refurbished facility can be used to understand the recycling process and the key requirements to make this effective.

#Have all the potential waste streams been identified? These include paper, cardboard, tin, glass, plastic, timber, electrical appliances etc?
#Have appropriate associations and local recyclers related to each of these waste streams been engaged with a view to ensuring that appropriate provision and systems are put in place to maximised recycling.

===Engagement with suppliers===
Engaging with suppliers can be used to reduce waste and transportation impacts. Waste and transportation impacts can be reduced through reduced use of packaging, use of reusable containers and optimized logistic supply chains.

#Have all suppliers of substantial goods and services to the health facilities been identified? Have these been engaged in relation to transportation and packaging with a view to minimising impacts in these areas?
#Has provision been made to reduce packaging waste and transport impacts through aspects such as increased space allowances for releasable containers and storage of products?

===Construction waste===
Construction is a major source of landfill waste. Waste from construction however can usually be easily reduced through explicit planning and monitoring processes.

#Has was construction waste minimization and recycling been included as specific requirement within tender and contract documents?
#Has the contractor been asked to develop a construction waste management plan in order to minimise waste? Does this plan include specific construction waste management targets ie 50% of all waste on site will be recycled? Have the parties responsible for implementing the plan been identified clearly and have they been given the mandate and resources to implement the plan? Has an appropriate monitoring and evaluation systems been put in place to ensure targets are achieved?

==MATERIALS==

===Objective===
Construction impacts of building are minimized

===Introduction===
Materials used in new facilities and the refurbishment of facilities can have significant impacts. Materials may be mined, processed, manufactured and transported before being incorporated in facilities. The extent and nature of the impacts of these stages varies widely depending on the material. The selection of materials and products to be used in facilities therefore is important in reducing negative environmental impacts.

Careful selection of construction materials used in health facilities has the following benefits:

*Reduced land and mining impacts
*Reduced environmental and health impacts from manufacturing processes
*Reduced transportation impacts
*Reduced material use
*Increased use of local sustainable materials

===Material use in health facilities===
Materials are used to construct South African health facilities and largely found in the building structure and envelope. More specialist materials and products such as refrigerants are found in equipment and systems within the building. The source and processes associated with construction materials and products have a wide range of impacts. It is therefore important to understand and confirm these with respective suppliers in order to select and specify materials and components with the least negative impacts.

===Criteria===
Material and component selection in health facilities can be addressed developing criteria list, communicating this to suppliers, and using this as a basis for specification and design. The nature of these criteria will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that key material and component considerations have been addressed. These are outlined below.

===Building reuse===
Using existing facilities instead of building new avoids or reduces the requirements for construction materials and therefore the impacts associated with extracting, manufacturing and transporting these. In addition, existing facilities are usually part of the urban fabric and already serviced with electricity, water, roads and public transport. Increasing the intensity of use of this fabric increases its efficiency and avoids the requirement to replicate this elsewhere. Therefore, in most circumstances it is preferable to reuse and refurbish existing facilities rather than build new facilities.

#Can the existing facilities continue to be used? If necessary, can these be refurbished and expanded rather than building a new facility?
#Are there other existing facilities that can be used? Can these be readily adapted for health use rather than constructing new facilities?

===Contribution to Global Warming===
Construction materials can contribute to global warming through carbon emissions associated with large amounts of energy used in their extraction, processing and transportation. This is referred to as embodied energy. Other materials such as refrigerant can contribute directly to global warming if they are released or leak into the atmosphere. Using existing facilities instead of building new avoids or reduces the requirements for construction materials and therefore the impacts associated with extracting, manufacturing and transporting these. In addition, existing facilities are usually part of the urban fabric and already serviced with electricity, water, roads and public transport. Increasing the intensity of use of this fabric increases its efficiency and avoids the requirement to replicate this elsewhere. Therefore, in most circumstances it is preferable to reuse and refurbish existing facilities rather than build new facilities.

#Refrigerants: Where refrigerants are being used in HVAC systems, cold rooms or in fire suppressions sytems have refrigerants with the lowest Global Warming Potential (GWP) and Ozone Depleting Potential (ODP) impacts been selected?
#High embodied energy materials: As far as possible, have construction materials with low embodied energy such as timber been selected? Where it is not possible to use these type of materials and high embodied energy materials such as cement and aluminium have to be use have the quantities of these materials been minimised?

===Reused materials or materials with recycled content===
Construction materials that are reused or have recycled content have less energy associated with their manufacture than equivalent new materials. Where possible, it is therefore preferable to reuse materials that may have already been used in another building or to select materials with recycled content.

#Are there materials from another building that is being demolished that could be reused? Aspects that can be reused include structure steel elements, facades, demountable structures such as carports, and building components such as windows and doors. Crushed concrete from demolished structures can also be used as aggregate in new construction.
#Have materials with recycled content been specified in preference to materials without any recycled content? Can the supplier / manufacture confirm the reduced environmental impacts of their recycled content product relative to new products?

===Reduced material use===
The quantity of construction materials used in facilities can be reduced through avoiding material use, using materials more intelligently and using materials for more than one use.

#Avoided material use: Have materials been avoided where these are not required? For instance, can ceilings and plastering be avoided through better concrete finishes? Can improved floor finishes be used to avoid the requirement for carpets and tiling? Can the use of passive systems reduce the requirement for ducting and plant?
#Intelligent material use: Can quantities of materials be reduced through different designs and specifications? For instance, can structural strategies such as pre-tensioning concrete slabs and waffle slabs be used to reduce concrete requirements? Can material use and wastage be reduced through use of precast elements?
#Dual plus use: Can materials be used for more than one purpose? For instance, can photovoltaic panels be used as a roofing material as well as to generate material?

===Material source===
The quantity of construction materials used in facilities can be reduced through avoiding material use, using materials more intelligently and using materials for more than one use.

#Avoided material use: Have materials been avoided where these are not required? For instance, can ceilings and plastering be avoided through better concrete finishes? Can improved floor finishes be used to avoid the requirement for carpets and tiling? Can the use of passive systems reduce the requirement for ducting and plant?
#Intelligent material use: Can quantities of materials be reduced through different designs and specifications? For instance, can structural strategies such as pre-tensioning concrete slabs and waffle slabs be used to reduce concrete requirements? Can material use and wastage be reduced through use of precast elements?
#Dual plus use: Can materials be used for more than one purpose? For instance, can photovoltaic panels be used as a roofing material as well as to generate material?

===Sustainable sources===
Materials can be defined in terms of whether they are from sustainable or non-sustainable sources. Materials from sustainable sources include timber, cork, wool that are grown and therefore can be harvested on an on-going materials. Other materials such as plastics and metals are mined and therefore once these sources are depleted will not be available.

#Where possible, have materials from sustainable sources been specified? For example, have timber, and plant-based products been used in preference to materials that have to be mined and processed?
#Are materials from sustainable sources actually being grown and harvested on a sustainable on-going basis? For instance, has timber specified been certified by the Forest Stewardship Council (FSC) as being from a sustainable source? It is important to note that there are still timber products available, in particular hardwoods, that are harvested from tropical rainforests which are not being replanted and therefore are not considered sustainable sources.

===BIODIVERSITY===

===Objective===
The building supports biodiversity

===Introduction===
Biodiversity plays a very important role for man through providing ecosystem services. Ecosystem services include the production of food and water, the control of climate and disease, supporting nutrient cycles and crop pollination and spiritual and recreational benefits.

Ensuring that health facilities take into account biodiversity has a wide range of benefits including:

*Maintaining local ecosystem services
*Providing an natural amenity such as gardens which would could support recuperation.

===Biodiversity in health facilities===
Health facilities affect biodiversity through their location and in the way that site planning and landscaping is carried out. New facilities can minimise negative impacts on biodiversity by avoiding green field sites and building outside municipal boundaries. Biodiversity within health facility sites can be supported through considered site planning and landscaping strategies.

===Criteria===
Biodiversity in health facilities can be addressed in a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key biodiversity considerations have been addressed. These are outlined below.

===Site location===
Biodiversity is being lost at a rapid rate through urban sprawl. Preserving existing biodiversity can therefore be achieved by avoiding green field site and building only within urban boundaries.

#Has the health facility been planned for a brown field (already built-on) sites?
#Has the health facility been planned for a location within an urban boundary so that this does not take up land that supports agriculture and or biodiversity.

===Design for biodiversity===
Biodiversity can be supported through site layouts and landscaping that retains existing biodiversity and enhances this.

#Has planning of the health facility ensured that existing valuable biodiversity on site is preserved?
#Have valuable links and wildlife corridors between biodiversity on the health facility and adjacent sites been preserved?
#Has the landscaping strategy enhanced existing biodiversity? Does this include the introduction of appropriate loc

==TRANSPORT==

===Objective===
The building supports energy efficient transportation

===Introduction===
Ensuring that health facilities support energy efficient transportation has a wide range of benefits including:

*Reduced air pollution and noise from vehicles
*Health benefits from increased opportunities for exercise
*More affordable transport for health facility users
*Reduced space requirements as a result of reduced parking and road requirements.

===Transportation in health facilities===
Transportation is important in health facilities as large numbers of people and goods need access to these facilities everyday. This includes health facilities staff who commute and health facilities users. The right location and provision of facilities help ensure that the transport impacts associated with this access is minimized and potential health benefits such as exercise are supported.

===Criteria===
The transportation in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that transportation considerations have been addressed. These are outlined below.

===Access to public transport===
Locating health facilities near public transport facilities and enabling good access to these encourage people to use these in preference to personal vehicles. The use of public transport can be encouraged by ensuring that health facilities are located near well used public transport nodes and that there are good walking routes between these and key locations within the health facility.

#Is the health facilities located near good public transport nodes such as minibuses, buses, trains and bus rapid transport systems?
#Are there safe, direct and easy-to-use routes between public transport nodes and key locations within the health facility? (see also provision for walking criteria)

===Provision for walking===
Making provision that encourages walking helps to ensure that people walk to health facilities instead of using vehicles. Walking can be encouraged through safe, direct and easy-to-use routes.

#Are there safe direct pedestrian routes to and around the health facilities site from neighboring areas and public transport nodes? (see also criteria 4 for detail)
#Are there safe direct pedestrian routes from neighboring areas to key locations within the health facility such as the main reception? (see also criteria 4 for detail)
#Are there safe direct pedestrian routes within the health facilities between all locations within the health facility? (see also criteria 4 for detail)
#Does pedestrian provision include safe road crossings such as bridges, underpasses and zebra crossings? Are routes wide enough and have appropriate finishes and other required characteristics to enable them to be easily used by people with disabilities and by predicted pedestrian numbers? Are routes safe and benefit from visual supervision by surrounding facilities and other pedestrians? Have lighting and appropriate security safety mechanisms been put in place if routes will be used at night?

===Provision for cycling===
Making provision that encourages cycling helps to ensure that people cycle to health facilities instead of using motorized vehicles. Cycling can be encouraged by providing secure cycle storage, changing or showering facilities and safe, easy-to-use local routes.

#Are there safe direct cycle routes to and around the health facilities site from neighboring areas? (see also criteria 4 for detail)
#Are there safe direct cycle routes from neighboring areas to key locations within the health facility such as the main reception? (see also criteria 4 below for detail)
#Are there safe direct cycle routes within the health facilities between all locations within the health facility? (see also criteria 4 for detail)
#Does this cycle provision include designated, separate routes and safe road crossings and junctions? Are routes wide enough and have appropriate finishes and other required characteristics to enable them to be easily used by predicted numbers of cyclists? Are routes safe and benefit from visual supervision by surrounding facilities and other cyclists? Have lighting and appropriate security safety mechanisms been put in place if routes will be used at night?

==RESOURCE USE==

===Objective===
The building makes efficient use of resources

===Introduction===
There are limited resources in the form of land, finance and raw materials to construct and maintain facilities. It is therefore important to use these resourced carefully. Benefits associated with careful resource use include:

*Avoiding waste
*Ensuring effective and efficient use of resources
*Ensuring that resources are available for other uses where these are not required

===Resource use in health facilities===
Health facilities use financial resources to enable construction and maintenance. They also consume materials and energy in their construction. Finally health facilities use land. Careful use of these resources enables waste to be avoided and these resources to be available for other uses where this is required.

===Criteria===
Resource in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that key resource considerations have been addressed. These are outlined below.

===Site density===
Detailed long term strategic plans for health facilities should be developed that take into account future projections. These should ensure that expansion or changes that are envisaged can be accommodated. However care should be taken that unnecessarily large areas are allocated for health facilities to avoid land being unused.

#Has a long term strategic site plan been developed for the health facility that addresses changes that may occur in the future, such as expansion or contraction?
#Has the over allocation of space for health facility sites been avoided?

===Occupancy density===
Robust sustainable facilities accommodate change through flexible and adaptable allocation and configuration of space. While this is important over provision of space should be avoided as this space will need to be serviced and maintained even if it is not used. Health facilities should therefore be designed to support spatial efficiency and effective use.

#Is the overall space allowance in the health facility in line or below health facilities norms, for instance, in terms of gross area per bed?
#Are the proportions of spaces use in the health facility in line with good practice health facilities design? For instance is the space allocated for circulation, support and ancillary services as a proportion of the total area in line with best practice norms?

===Food production===
Food production in the form of orchards or vegetable gardens are a productive way of using land that leads to both environmental and health benefits. Where land is available in health facility sites and there is water and appropriate capacity, food production should be encouraged and produce made available to be consumed within the health facility or by local communities.

#Has available land within the health facility site been developed for local food production?
#Has appropriate provision in the form of irrigation, fencing, organizational and capacity requirements been made to ensure that food production will be effective and sustained?

==MANAGEMENT==

===Objective===
The building is managed to support sustainability

===Introduction===
Facilities can be designed to support effective management. Systems can also be developed to ensure that facilities are effectively and efficiently used and maintained. In health facilities this is particularly important because of the stringent environmental requirements for health care and the high operating costs of the facility.

Ensuring that health facilities are effectively managed has a wide range of benefits including:

*Ensuring that operating costs are controlled and reduced
*Minimising disruption to health care as result of maintained and repairs
*Ensuring that maintenance is planned for and effective carried out

===Building management in health facilities===
Building management aims to ensure that health facilities are effectively operated and maintained in order to support healthcare services that they accommodate. Personnel with appropriate capacity, mandate and resources should be allocated to this function.

===Criteria===
Building management in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that building management considerations have been addressed. These are outlined below.

===Energy and water sub metering===
Energy and water sub metering enables the manager of a health facility to manage the consumption of energy and water and reduce costs associated with these services.

#Has energy sub metering been installed which enables energy consumption in all areas with substantial loads to be measured and monitored? Do energy meters support assessment of energy consumption trends, profiles and comparison with benchmarks?
#Has water sub metering been installed which enables water consumption in all areas with substantial consumption to be measured and monitored? Do water meters support assessment of water consumption trends, profiles and comparison with benchmarks?
#Is water and energy consumption monitored and reported to senior management on a regular basis?

===Facilities management manual===
A facilities management manual provides technical detail on all aspects of the building and how they should be maintained and managed. It is useful because it provides a repository of knowledge and information that can be used by facilities managers and their staff to ensure that health facilities are effectively managed and maintained.

#Has a detailed facilities management manual been developed for the health facilities? Does this include a detailed schedule for maintenance and other checks on equipment such as lighting, pluming fittings and HVAC
#Does the facilities management manual refer to a full set of as-built drawings and equipment manuals? Have a full set of hard copy and electronic copy as-built drawings and manuals been provided?
#Have facilities managers in the building had a full induction on the building’s systems and the facilities management manual?
#Does the facilities management manual get regularly reviewed and updated to reflect upgrade and renovations details.

===Senior management commitment===
Effective management of facilities can be supported by senior management commitment. Regular reporting on facilities performance such as energy and water consumption serve to ensure that management is aware of these issues and are likely to ensure that the appropriate mandate and resources are in place to improve this.

#Have facilities management policies in relation to sustainability been developed? For instance, are there policies or guidance on how energy and water consumption will monitored and managed?
#Have facilities management policies or guidelines been endorsed by senior management? Is there are requirement for facilities management to report on facilities performance on a regular basis to senior management?

==LOCAL ECONOMY==

===Objective===
The building supports the local economy

===Introduction===
The construction and maintenance health facilities are a significant investment by government. This investment, if considered carefully, can be used to support the local economy and employment. This is done by specifying local products and services from the local area.

Ensuring that health facilities support the local economy has a wide range of benefits including:

*Increased local employment
*Increased local capacity for new construction and maintenance of facilities

===Local economy in health facilities===
Supporting the local economy can be achieved in new facilities by understanding the nature and type of local building product suppliers and where appropriate specifying these in the building. Similarly understanding the capacity and skills of local contractors can be used to ensure that these are developed and enhanced by being engaged in the construction and maintenance of health facilities.

===Criteria===
Supporting the local economy in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key waste considerations have been addressed. These are outlined below.

===Small enterprise support===
The waste and emissions in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key waste considerations have been addressed. These are outlined below.

Minimizing irrigation water requirements can be used to reduce water consumption. The following measures can be considered:

#Are small enterprises provided with opportunities to tender for relevant construction and maintenance contracts? Can local, small enterprises be given preference in the awarding of work?
#Where local small enterprises have limited capacity and experience, can they be supported by encouraging partnerships with more established and larger enterprises?

===Material and component procurement===
The specification of local materials and components in the construction of health facilities can provide a significant incentive to local suppliers and manufacturer to develop appropriate products and capacity. This in turn provides local employment and can ensure that maintenance and repairs at the facilities can be carried out more quickly and cost effectively.

#Has a review of local materials and components been carried out?
#Have local materials and components been specified?

===Construction employment===
The construction industry can employ significant numbers of people. This can be supported through designs, specifications and labour intensive construction techniques which can be used to construct facilities without significant cost or time implications. Local construction employment improves the local economic impact of projects and ensures that there is local capacity to undertake repairs and maintenance of facilities.

#Is construction employment a key consideration in the design, specification and construction of the facility?
#Have opportunities to create local employment been sought and developed through the project?

==PRODUCTS AND SERVICES==

===Objective===
The building supports use of more sustainable products and services

===Introduction===
Products and services used in health facilities have a range of impacts and planning can be used to maximise beneficial impacts and avoid negative impacts. The construction and maintenance health facilities are a significant investment by government. This investment, if considered carefully, can be used to support the local economy and employment. This is done by specifying local products and services from the local area.

Ensuring that health facilities support the more sustainable products and services has a wide range of benefits including:

*Reduced waste
*Increased support for sustainable choices and options for health facility users

===Products and services in health facilities===
Supporting the local economy can be achieved in new facilities by understanding the nature and type of local building product suppliers and where appropriate specifying these in the building. Similarly understanding the capacity and skills of local contractors can be used to ensure that these are developed and enhanced by being engaged in the construction and maintenance of health facilities.

===Criteria===
Supporting the more sustainable products and services in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key product and service considerations have been addressed. These are outlined below.

===Local produce===
Impacts associated with transport and storage / refrigeration mean that produce imported from some distance away generally has significantly higher ecological footprints than local produce. Health facilities can therefore reduce ecological footprints associated with food through using local produce as far as possible.

#Is local produce used in preference to produce imported some distance away?
#Has the use of local produce been made a requirement in outsourced catering contracts?

===Vegetarian options===
Meat-based meals generally have significantly higher ecological food print requirements relative to vegetarian meals. Providing vegetarian options can therefore support reduced food impacts within health facilities.

#Are vegetarian options provided in catering establishments within the health facility?
#Has the provision of vegetarian options been made a requirement for outsourced catering contracts?

===Drinking water===
Waste streams can be reduced by providing alternatives to bottled drinking water. Drinking water can be provided through strategically located drinking fountains, as well as being supplied in reusable containers. A ready supply of drinking water also has health benefits.

#Is non-bottled drinking water readily and freely available throughout the health facility?

===Reuseable vessels===
Significant waste streams can be avoided through the use of reusable vessels. In particular disposable food and drink vessels can be avoided by providing reusable vessels. This option can be supported through provision of required storage and washing and facilities.

#Have reusable vessels been specified in preference to disposable containers, for services such as catering?
#Has adequate provision been made for reusable vessels in the form of storage and washing facilities?

==ACCESS==

===Objective===
The building supports access to facilities

===Introduction===
Current work patterns and lifestyles mean that many people have to access facilities such as banking, retail, childcare and communications on a regular basis. Ensuring that these facilities are within the health facility or within easy walking distance helps to avoid or reduce associated time and transport impacts.

Ensuring that health facilities support access to facilities has a wide range of benefits including:

*Reduced transport impacts
*Reduced time spent travelling to and from facilities

===Access to facilities in health facilities===
Supporting access to local facilities can be achieved through incorporating these into the health facility. Alternatively the health facility can be located near where these exist. It may also be possible to work with relevant service providers in order to provide these locally.

===Criteria===
Supporting access to facilities in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key access considerations have been addressed. These are outlined below.

===Banking===
Access to banking can be provided through formal banking facilities or through bank ATMs. This can be provided within the health facility or within easy walking distance of this.

#Are banking facilities available within the health facilities or within the local area?

===Grocery retail===
Grocery retail can be provided through local shops, supermarkets and markets. This can be provided within the health facility or within easy walking distance of this.

#Are grocery retail facilities available within the health facility or within the local area?

===Communication===
Access to telephone and internet can be provided through internet cafes or at stand alone kiosks. This can be provided within the health facility or within easy walking distance of this.

#Are internet and telephone facilities available within the health facility or in the local area?

===Café===
Access to catering facilities can be provided through cafes, restaurants or canteens. Refreshments should be affordable and accessible to both staff and health facility users. This can be provided within the health facility or within easy walking distance of this.
1. Is there an accessible, affordable café, restaurant or canteen within the health facility or in the local area?

===Childcare===
Significant waste streams can be avoided through the use of reusable vessels. In particular disposable food and drink vessels can be avoided by providing reusable vessels. This option can be supported through provision of required storage and washing and facilities.

#Is there a childcare facility within the health facility or in the local area?

==HEALTH==

===Objective===
The building supports a healthy and productive environment

===Introduction===
Health facilities by their definition aim to support health and well being in their users. In addition to medical care health can be promoted through beneficial environmental conditions including a plentiful supply of fresh air, views and optimum thermal comfort conditions. It is particularly important to avoid conditions and situations that may be harmful to human health.
Ensuring that health facilities support the health in facility users and construction workers services has a wide range of benefits including:

*Improved recovery rates for patients
*Reduced absenteeism associated with environmental conditions by health facility staff
*Reduce injury and absenteeism rates associated with dangerous or harmful working construction environments

===Criteria===
Ensuring construction and health facilities promote health can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that health promotion considerations have been addressed. These are outlined below.

===External views===
Views and a connection to the external environment improve internal environmental conditions and can help improve recovery rates and reduce employee absenteeism.

#Do health facility staff working areas have views to the external environment
#Do patient areas have views of the external environment?

===Daylight===
Day lighting can help reduce energy consumption associated with artificial lighting. It also improves internal environmental conditions for patients and health facility employees.

#Are health facility staff working areas well day lit?
#Are patient areas well day lit?

===Ventilation===
High levels of fresh air are important for human health and productivity. This can be provided through natural or mechanical ventilation. Where mechanical ventilation is used sufficiently high levels of external, fresh air should be provided and recirculated air should be avoided or minimized.

#If the condition of outside air makes it unfit for direct ventilation use, is it appropriately pre-treated and filtered by the ventilation system?
#Are health facility staff working areas well supplied with good quality outside air?
#Are patient areas well supplied with good quality outside air?

===Building materials===
Building materials can have negative impacts for human health associated with their extraction and manufacture. They may affect health in facilities, through for instance offgassing hazardous chemicals. Construction materials should therefore be screened to avoid products being used in health facilities that have negative impacts on human health.

#Has criteria been developed and applied for the selection and screening of building materials?
#Have all building materials that may off gas substances such as formaldehyde and volatiles organic components that may be harmful to human health been avoided?

===Contractor health and safety===
There are considerable health and safety risks in the construction industry. Considering health and safety in the design of health facilities can be used to reduce health and safety risks associated with construction and maintenance. Making provision for safe access to glass facades or to high level lighting helps to ensure that this can be installed, cleaned and maintained without undue health and safety risks. In addition, addressing health and safety comprehensively in contract and construction planning, procedures and processes can be used to eliminate many construction health and safety risks.

#Has contractor health and safety been considered as a key issue in the design of the building? Have construction risks been minimised through appropriate design risk assessments and mitigation?
#Have detailed construction plans, procedures and processes been developed to minimise risks where these may occur during construction?
#Has appropriate health and safety procedures been put in place to ensure that plans are implemented and monitored?

==EDUCATION==

===Objective===
The building supports education

===Introduction===
Education and on-going learning is increasingly been seen as an essential component of sustainable development and a competitive economy. This is recognised in health care through the requirement for health care professionals to under continued professional development (CPD). Education and on-going learning can be supported through technology and spaces within facilities that support this. Examples of this include training rooms and access to ICT and reading material. In addition well packaged
Ensuring that health facilities support the education has a wide range of benefits including:

*Improve ability by health facilities staff to keep up-to-date with new developments in health care
*Ability to attract and retain staff

===Criteria===
Ensuring construction and health facilities promote education and on-going learning can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that education and on-going learning considerations have been addressed. These are outlined below.

===Contractor education===
There are considerable health and safety risks in the construction industry. Considering health and safety in the design of health facilities can be used to reduce health and safety risks associated with construction and maintenance. Making provision for safe access to glass facades or to high level lighting helps to ensure that this can be installed, cleaned and maintained without undue health and safety risks. In addition, addressing health and safety comprehensively in contract and construction planning, procedures and processes can be used to eliminate many construction health and safety risks.

#Has contractor health and safety been considered as a key issue in the design of the building? Have construction risks been minimised through appropriate design risk assessments and mitigation?
#Have detailed construction plans, procedures and processes been developed to minimise risks where these may occur during construction?
#Has appropriate health and safety procedures been put in place to ensure that plans are implemented and monitored?

===Notice boards===
Notices are very easy and cost effective way of communicating information. They can be used to support education and awareness by drawing attention to new or important education. For instance, awareness and reminders about new health care policy, procedures and processes can be communicated. Notice boards have the benefit that they can be located where they will be seen by all personnel on a regular basis and are not reliant on a particular technology, such as email. This helps to ensure information can be communicated to all levels of staff within a health facility.

#Have notice boards been located in key locations in the health facility where they can be used to communicate key information to facility staff and users?
#Have communication and education plans been developed that will ensure that notice boards will be updated throughout the year with relevant notices and information?

===Space for learning===
Formal training can be supported through access to training rooms. More informal on-going learning can be provided through access to resource centres where learning material, computers and the internet can be accessed.

#Are there appropriately sized and equipped facilities to accommodate formal training?
#Are there appropriately sized and equipped facilities to support informal on-going learning by staff?

===Employee induction===
Employee induction refers to awareness training provided to new employees. This can be used to support sustainability by developing awareness in health facility staff about sustainable building systems and how they should be used. This may include aspects such as lighting and HVAC operation as well as recycling procedures.

*Have employee induction processes been developed?
*Do these include detailed information on systems in the building that aim to support sustainability?

===Building user manual===
Building user manuals aim to complement employee induction processes by providing easily accessible and understanding information related to a facility in order to support user behaviour that support sustainability.

#Has a building user manual been developed?
#Is this readily accessible and easy to use?

==INCLUSION==

===Objective===
The building is inclusive of diversity in population

===Introduction===
Design for inclusion helps to ensure that facilities can be used by all users including older people, sick people, people with children and people with disabilities. Inclusive design also often means that facilities are safer and easier to use. In health facilities both of these aspects are particularly important.

Ensuring that health facilities are inclusive has a wide range of benefits including:

*Less requirement to replicate facilities
*Facilities that are easier and safer to use

===Criteria===
Ensuring health facilities are inclusive can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key inclusion considerations have been addressed. These are outlined below.

===Accessible transport===
Inclusive access to health facilities is an important consideration. This means ensuring that people who may be ill, infirm, old or have disabilities are able to access health facilities easily. This requires accessible routes from places for work and accommodation to the facilities and often requires easily accessible local public transport systems. This can be p

Ensuring that health facilities support the education has a wide range of benefits including:

#Are there regular, affordable and efficient local transport systems?
#Can these be accessed readily from health facility users’ accommodation and places of work?
#Can the health facility be accessed readily from public transport?
#Is public transport provision inclusive?

===Environmental access===
Facility design and management for environmental access can be used to ensure that health facilities are inclusive. This requires a comprehensive approach that ensures that access consideration are effectively integrated into all aspects of health facility design. Guidance on this aspect is provided in the IUSS d

#Does the facility design fully comply with the IUSS environmental access requirements?
#Are systems and management in place to ensure that environmental access standards are maintained during operation?

===Access to affordable accommodation===
There is an increasing shortage of affordable accommodation in many South African cities. This can have a range of negative impacts including the requirement for long distance commuting, disrupted family life, and reduced family budgets for non-transport related costs such as education and health. Increasing local affordable accommodation can be achieved through partnership agreements with local developers and social housing organizations.

#Is there affordable local accommodation for health facility staff?
#If this does not exist, have initiative been taken to develop this with developers and or social housing institutions?

==SOCIAL COHESION==

===Objective===
The building supports social cohesion

===Introduction===
Social cohesion refers to the extent to which individuals within a community understand, collaborate, trust and work together. It is valuable because it enables collective knowledge and resources to be used more effectively and efficiently to support common goals. Within a health facility improved social cohesion can support improved healthcare with fewer resources by sharing and using these more effectively. It can also support improved communication and cooperation within health teams and therefore improving levels of service and reducing wastage and mistakes.

Ensuring that health facilities support social cohesion has a wide range of benefits including:

*More efficient and effective use of resources
*Improved communication and coordination
*Reduced wastage

===Criteria===
Ensuring health facilities support social cohesion can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key social cohesion considerations have been addressed. These are outlined below.

===Shared used of facilities===
Shared use of facilities helps to ensure that valuable facilities are well used and beneficial impacts are experienced across a wider range of people. Capital and operating costs of the facility may also be reduced as these are shared between a larger number of organizations or individuals. This concept can be applied to health facilities in a range of different ways. For instance, sharing arrangements with a local sport club or fitness center can be used to enable a health facility to use swimming pools and other facilities for rehabilitation without having the ongoing costs and management of this facility.

#Have shared use, and possibly development, of facilities been explored with local organizations?
#Have appropriate design considerations been put in place to ensure effective shared use of facilities?
#Have appropriate management considerations been put in place to ensure effective shared use of facilities?

===Social spaces===
Social spaces, such as canteens, cafes and common rooms can play an important role in the life of organization. They not only provide a respite from work environments they also provide a space for relaxed social interaction. This interaction and the relationships and communication networks created can may a significant impact in improving organizational effectiveness and responsiveness. In health care facilities this is a valuable resource which helps to motivate individuals and build strong teams that are able to provide effective and responsive health care.

#Have an appropriate number and type of social spaces been provided within the health facility?
#Will these facilities support easy social interaction within and between health teams, as well as cross health facility staff structures?

===Stakeholder involvement===
Involving people in decisions on issues will have an impact on them is a useful way of helping ensure that there is support for an initiative or a process. Structured involvement of stakeholder helps to ensure a shared understanding can be developed, joint decisions made and there is efficient and effective implementation. For instance, within a health facility, effective involvement of key stakeholders can help goals such as improved energy efficiency through ensuring that managers, building technical staff and health services staff understand the goal, the means that this will be achieved and can see their role in supporting this.

#Has there been appropriate stakeholder involvement in the design of health facilities?
#Has there been appropriate stakeholder involvement in the management of health facilities?

==REFERENCES==

#[http://www.cidb.org.za/publications/Documents/Greenhouse%20Gas%20Emission%20Baselines%20and%20%20Reduction%20Potentials%20from%20Buildings%20in%20South%20Africa.pdf CIDB, 2009. South African Report on Greenhouse Gas Emission Reduction, Potentials from Facilities, A Discussion Document. Construction Industry Development Board. Page 22].
#. DEAT, 1995. Urban Open Space: Guidelines for effective management. Discussion document based on Agenda 21 and the RDP
#[https://www.environment.gov.za/sites/default/files/gazetted_notices/nema_guidelines_g33333gen654_0.pdf DEAT, 1998. National Environmental Management Act. Department of Environment and Tourism, Pretoria. Chapter 1.]
#[https://resource.capetown.gov.za/documentcentre/Documents/City%20research%20reports%20and%20review/State_of_Environment_Report_2009_2010-08.pdf DEAT 2009, State of the Environment Report] Accessible from http://soer.deat.gov.za/themes.aspx?m=387
#[https://www.environment.gov.za/sites/default/files/legislations/national_climatechange_response_whitepaper_0.pdf DEAT, 2009a, The National Climate Change Response Policy. Department of Environment and Tourism, Pretoria. Page 8.]
#[https://www.environment.gov.za/sites/default/files/legislations/national_climatechange_response_whitepaper_0.pdf DEAT, 2009b, The National Climate Change Response Policy. Department of Environment and Tourism, Pretoria. Page 14]
#[https://www.environment.gov.za/sites/default/files/legislations/national_climatechange_response_whitepaper_0.pdf DEAT, 2009c, The National Climate Change Response Policy. Policy Department of Environment and Tourism, Pretoria. Page 20].
#[https://www.ekurhuleni.gov.za/council/reports/environmental-reports/469-environmental-managment-framework-2008/file.html EMM and GDACE, 2007. Environmental Management Framework for Ekurhuleni. Ekurhuleni Metropolitan Municipality and Gauteng Department of Agriculture, Conservation and the Environment]
#[https://www.researchgate.net/publication/260034209_General_conclusions_on_development_of_plausible_climate_change_scenarios_for_southern_Africa Hewitson, B. Engelbrecht, F Tadross, M. and Jack, C., 2005. General conclusions on development of plausible climate change scenarios for southern Africa, in: R. E. Schulze (ed.), Climate Change and Water Resources in Southern Africa: Studies on Scenarios, Impacts, Vulnerabilities and Adaptation, Water Research Commission, WRC Report 1430/1/05, Pretoria, South Africa.]
#[https://www.ipcc.ch/site/assets/uploads/2018/02/ar4_syr_full_report.pdf IPCC, 2007. Climate Change 2007, Synthesis Report. Inter Governmental Panel on Climate Change. 2007.Page 7]
#[https://www.cityenergy.org.za/uploads/resource_82.pdf SEA 2006, . Sustainable Energy Africa. Cape Town.]
#[http://www.woodybpower.biz/Sans%20204.pdf South African Bureau of Standards. 2007. SANS 204 Energy Efficiency in Facilities]
#[http://awsassets.panda.org/downloads/lpr_living_planet_report_2004.pdf WWF 2004. Living Planet Report 2006.World Wildlife Fund].

==APPENDIX A: SUSTAINABILITY INTEGRATION PLANS==
 
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[[Category:Crosscutting Issues]]

Sustainability

2021-05-05T05:52:29Z

Tmojanaga: /* REFERENCES */

==INTRODUCTION==

==Purpose==
This document has been developed for the Department of Health to ensure that sustainable development is integrated into to planning and design of health facilities. The document defines sustainable development and outlines the implications of this for the built environment. It provides objectives and criteria that can be used in the development health facilities in South Africa.

==Background==
The Department of Health wish to support sustainable development in South Africa and ensure that there is an appropriate balance between economic development, social integration and protection of the environment.
Global Warming and South African legislation and policy now make it imperative that built environment projects address sustainability. However, there is limited South African guidance on how sustainable development can be integrated with built environment projects. There is also the perception that addressing sustainability in facilities will be expensive and complicated.
This document provides guidance and checklists that can be used to support the integration of sustainability into health facilities. It shows that by addressing sustainability early in projects, additional costs can be minimised and innovative, high-performance solutions that benefit society, the economy and the environment can be achieved. It also shows that achieving more sustainable facilities need not be complex but can be based on robust, sensible and simple measures.

==How to use this document==

This document provides a framework that can be used to inform the development of health facilities. It can be used in the following ways:

*'''Awareness''': This document can be used to increase awareness about sustainable development and the need to address this in built environment projects. This will lead to more rigorous debate on development options and support more innovative and sustainable solutions.

*'''Setting sustainable development targets''': This framework can be used by a development team to set explicit and challenging sustainable development targets for projects. This is done by setting quantified targets against criteria in the document and putting in place systems to ensure that these are achieved.

*'''Self-assessments''': This framework can also be used for self-assessment and to ascertain the performance of development proposals. To carry this out refer to the Facility Recommended Compliance sheet and Compliance Checklist at the end of the document. This enables different health facility development proposals to be evaluated in terms of recommended compliance. Assessment using the criteria can also inform the design process by being used to evaluate different development options. This enables optimal solutions to be developed in an iterative and efficient way.

*'''Coordinated development''': Some criteria in the document may appear not to be in the remit of, or possible in, a single development. These criteria however can be achieved through partnerships and local collaboration. This framework can be used bring together the key role players in order to develop integrated plans that enable key sustainable development objectives to be achieved.

==Structure of the guideline==
The document has the following structure:

*'''Implementing Sustainable Development''': This section provides a description of sustainable development and translates this into specific sustainable development objectives for the built environment.

*'''Built Environment Sustainable Development Objectives''': In this section more detailed guidance and checklists are provided for each of sustainable development objectives listed in the section above.

*'''Sustainability Integration Plans''': This provides guidance on plans and a structure that can be used to integrated sustainability in design and operational processes.

==IMPLEMENTING SUSTAINABLE DEVELOPMENT==

===Introduction===
South Africa faces a range of social, economic and environmental challenges. HIV/AIDs has resulted in a life expectancy dropping from 67 years in 1998 years to around 47 years currently. Unemployment is estimated to be 27% and climate change is likely to lead to increasing water stress, reduced food security and loss of species and ecosystems (DEAT 2009).
Sustainable development, which aims to achieve social and economic improvements while reducing negative environmental impacts, can be used to address these challenges. Sustainable development however can be difficult to achieve. This is because a holistic and integrated approach is required and the development sector and in particular, the construction industry, operates in a highly fragmented way. In addition, the concept of sustainable development is still new and has not been adequately translated into practical actions that can be readily implemented.
This section defines sustainable development and translates this into key built environment objectives. It also describes the role of the built environment in creating environmental and other problems and shows how integrating sustainable development considerations into construction and the built environment can make a substantial contribution to improving the social, economic and environmental performance of the built environment.

===The environmental context===
Increasing carbon emissions from human activities and a reduction in the ability of the natural environment to absorb carbon dioxide is leading to an accumulation of greenhouse gases in the upper atmosphere. These gases trap more heat in the upper atmosphere leading to global warming and temperatures are predicted to increase by 2 - 6°C OC by the end of the century (IPCC, 2007). Estimates carried out for the City of Joburg indicate that temperatures in the next 50 years may increase between 2 and 3.5°C (Hewitson, Engelbrecht, Tadross, Jack, 2005).

Within Africa, South Africa produces the highest CO2 emissions and has one of the highest CO2 emissions per GDP in the world. In 2002, carbon emissions per capita in South Africa were 8.4tonnes/capita - higher than Western European averages of 7.9tonnes/capita (SEA 2006).
Global warming is likely to impact Africa particularly negatively. The National Climate Change Response Policy Developed by the Department of Environment and Tourism outlines the following impacts (DEAT 2009a):

*Agricultural production and food security in many African countries are likely to be severely compromised by climate change and variability. Projected yields in some countries may be reduced by as much as 50% in some countries by 2020 and as much as 100% by 2100. Small scale farmers will be most severely affected.

*Existing water stresses will be aggravated. About 25% o Africa’s population (about 200million people) currently experience high water stress. This is projected to increase to between 75-250 million by 2020 and 350-600 million by 2050.

*Changes in ecosystems are already being detected and the proportion of arid and semi-arid lands in Africa is likely to increase by 5-8% by 2080. It is projected that between 25 and 40% of mammal species in national parks in sub-Saharan Africa will become endangered.

*Projected sea-level rises will have implications for human health and the physical vulnerability of coastal cities. The cost of adaptation to sea level rise could amount to 5-10% of gross domestic product.

*Human health will be negatively affected by climate change and vulnerability and incidences of Malaria, Dengue fever, Meningitis and Cholera may increase.

===The contribution of the built environment===
Construction and the built environment make a substantial contribution to global warming and play a significant role most economies. Environmental, social and economic impacts attributed to the built environment at a global scale are outlined below.

*Consumes 40% of energy use,

*Consumes 17% of fresh water use,

*Consumes 25% of wood harvested,

*Consumes 40% of material use,
*Employs 10% of the world’s work force,

*Construction is the largest employer of micro-firms (less than 10 people),

*Facilities are typically located on the most productive land (Estimated to be 250 million hectares world wide, mostly on primary agricultural land).

In South Africa the built environment is directly responsible, through electricity consumption, for over 23% of South Africa’s carbon emissions (see table below). Vehicle-based infrastructure and transport planning has resulted in transport contributing to 16% of South Africa’s CO2 emissions and an additional 18mtCO2 per year, or about 4% of South Africa’s CO2 emissions, come from the manufacture of building materials (CIDB 2009).

Sector C02 Emissions

Commercial 10%

Residential 13%

Transport 16%

Industry 40%

Mining 11%

Other 10%

Total 100%

''Figure 1: South African carbon emissions per sector''

===Defining sustainability===
Recent work by the World Wildlife Fund contributes substantially to defining sustainable development by providing quantified minimum criteria for sustainability. In the 2006 Living Planet Report, sustainability is defined as achieving an Ecological Footprint (EF) of less than 1.8 global hectares per person and an Human Development Index (HDI) value of above 0.8 (WWF 2006).

===Ecological Footprint===
An Ecological Footprint is an estimate of the amount of biologically productive land and sea required to provide the resources a human population consumes and absorb the corresponding waste. These estimates are based on the consumption of resources and production of waste and emissions in the following areas:

*Food, measured in type and amount of food consumed,

*Shelter, measured in size, utilization and energy consumption,

*Mobility, measured in type of transport used and distances travelled,

*Goods, measured in type and quantity consumed.

*Services, measured in type and quantity consumed The area of biologically productive land and sea for each of these areas is calculated in global hectares (gha) and then added together to provide an overall ecological footprint. This measure is particularly useful as it enables the impact of infrastructure and lifestyles to be measured in relation to the earth’s carrying capacity of 1.8 global hectares (gha) per person.

===The Human Development Index===
The Human Development Index was developed as an alternative to economic progress indicators and aimed to provide a broader measure that defined human development as a process of enlarging people’s choices and enhancing human capabilities (United Nations Development Programme 2007). The measure is based on:

*A long healthy life, measured by life expectancy at birth,

*Knowledge, measured by the adult literacy rate and combined primary, secondary, and tertiary gross enrolment ratio,

*A decent standard of living, as measure by the GDP per capita in purchasing power parity (PPP) in terms of US dollars.

===South African EF and HDI figures===
The figures below show that South Africa has an ecological footprint of 2.1, above the maximum required of 1.8 gha and a human development index measure of 0.66, below the minimum of 0.8 required for sustainability.

Measure South Africa Sustainability Target
Ecological Footprint (gha) 2.1 1.8
Human Development Index 0.658 0.8
{| class="wikitable"
|+
!Measure
!South Africa
!Sustainability Target
|-
|Ecological Footprint (gha)
|2.1
|1.8
|-
|Human Development Index
|0.658
|0.8
|}

For South Africa to move towards sustainability there must therefore be an improvement in both the Ecological Footprint and Human Development Index performance. The built environment has a key role in supporting this improvement.

===The legislative and policy context===
South Africa has a range of legislation and policy that aims to protect the environment and support sustainable development. Key legislation supporting sustainable development includes the South African Constitution and the National Environmental Management. These are discussed briefly below.

===South African Constitution===
The South African Constitution contains a Bill of Rights that enshrines the rights of all people in South African and affirms the democratic values of human dignity, equality and freedom. The Bill has sections covering equality, human dignity, privacy, freedom of religious belief and opinion, environment, property, housing, healthcare, food, water and social security, children, education, language and culture. Through a section on equality, the Bill requires that all people have full and equal enjoyment of these rights and freedoms:

''Everyone is equal before the law and has the right to equal protection and benefit of the law.''

Equality includes the full and equal enjoyment of all rights and freedoms. To promote the achievement of equality, legislative and other measures designed to protect or advance persons or categories of persons, disadvantaged by unfair discrimination, may be taken.
Environmental rights in the Bill of Rights include the right to an environment that supports health and wellbeing. It also requires legislation to be developed to ensure that the environment is protected and that development that does occur is both sustainable, and justifiable:

===Environment===
Everyone has the right

a). to an environment that is not harmful to their health or well-being; and

b). to have the environment protected, for the benefit of present and future generations, through reasonable legislative and other measures that ¬

#prevent pollution and ecological degradation;
#promote conservation; and
#secure ecologically sustainable development and use of natural resources while promoting justifiable economic and social development.

Sustainable development and the protection of the environment is, therefore, a constitutional obligation and there is a requirement for ‘reasonable legislative and other measures’ to be put in place to ensure that this achieved. '''This document represents a measure taken by the Department of Health to achieve sustainable development.'''

===Carbon emission mitigation strategies===
South Africa is a signatory to both the United Nations Framework Convention on Climate Change (UNFCC) and the Kyoto Protocol. In order to address UNFCC commitments, the Long Term Mitigation Scenarios (LTMS) process was initiated in 2006 and completed in 2008. This formulated strategies to ensure that South Africa would reduce carbon emissions. Many of the mitigation strategies identified have implications on the built environment and these are outlined below (DEAT 2009b):

*Limits on less efficient vehicles

*Passenger modal shift
*Solar water heater subsidy

*Commercial efficiency
*Residential efficiency

*Renewables with learning

*Waste management

*Land use: afforestation

*Escalating CO2 tax

Following the LTMS process, key policy approaches were agreed on by the South African cabinet. These strengthen current energy efficiency and demand-side management initiatives such as environmental fiscal reform and carbon taxation which will penalize energy inefficient technology and provide for additional tax allowances of up to 15% for energy-efficient equipment.
The LTMS process however also showed that although significant emission reductions could be achieved through technology-based actions, these were not sufficient for the scale of change required and that adaptations in social behaviour would be required. (DEAT 2009c).The LTMS, therefore, proposed a number of people and building orientated measures that offered low-cost large scale mitigation impacts including:

*Social adaptation and changes in human habitation, urban planning and the built environmental

*Studies on the distance between work, home and other life functions

*Modal shifts to public transport and moves away from individual car owners towards the operation of shared vehicles

*Food production and consumption, as well as the localization of these activities

==Built environment sustainable development objectives==
The environmental context, legislation and potential future measures to reduce carbon measures make it clear that the built environment must change to support sustainable development. It also makes it clear that many of the conventional practices in the planning, design, construction and management of building must be substituted with improved more sustainable approaches.
In order to develop practical measures that can be integrated into the built environment, it is useful to set out built environment or development objectives that, together, would support sustainable development. These objectives are outlined below and form the starting point for the next sections of this document where more detailed criteria are provided.

===Environmental objectives===

*Energy: The building is energy efficient and uses renewable energy

*Water: The building minimises the consumption of mains potable water.

*Waste: The building minimizes emissions and waste directed to landfill

*Materials: Construction impacts of building are minimized
*Biodiversity: The building supports biodiversity

===Economic objectives===

*Transport: The building supports energy efficient transportation
*Resource Use: The building makes efficient use of resources
*Management: The building is managed to support sustainability
*Local Economy: The building supports the local economy
*Products and Services: The building supports use of more sustainable products and services

===Social objectives===

*Access: The building supports access to facilities

*Health: The building supports a healthy and productive environment

*Education: The building supports education
*Inclusion: The building is inclusive of diversity in population

*Social Cohesion: The building supports social cohesion

===Integrating sustainable development objectives into health facilities===
Integrating sustainable development objectives requires structured processes. These are described below in terms of design and operational processes.

===Design processes===
Addressing sustainability in designs for new health facilities can be achieved through the following steps:

'''Target setting:''' Challenging sustainability targets should be set for the building and agreed with all of the key stakeholders of the project including the design team, the facilities manager and the funder or owner of the building. Targets should take into account government policy and strategies as well as local and international best practice.

2. '''Design principles:''' Strategies and design principles required to achieve these sustainability objectives should be understood and established from the outset. For instance, energy targets may require passive environmental control strategies to be well understood and established from the outset. These strategies and their implications can be understood through analysis of best practice examples and precedents.

3. '''Integrated design:''' Once targets and design principles have been established, an integrated design process should be used to ensure that all aspects of the building work together to achieve the required performance. This requires the different disciplines to work closely together.

4. '''Testing:''' Throughout the design process, checks should be carried out to ensure that targets set will be achieved. This can be done through calculations, modelling and analysis which assesses performance against targets set. Where aspects of the design are found not to meet targets a re-evaluation of the design should be carried out and in an iterative and integrated way, improved, to ensure that performance achieves, or surpasses, targets set.

5. '''Detailed design and implementation:''' It is important to ensure that the principles set out in 2 above, are carried out in to detail otherwise this may affect operational performance. This includes, for instance, details such as appropriate locations for switches, labels and instructions.

6. '''Handover:''' On completion, effective processes should be followed to ensure that design intentions are carried through into building operation. This includes effective commissioning, handover and training processes which ensure that designers, subcontractors and suppliers transfer knowledge and skills to facilities managers required to ensure effective management of the building.

===Operational performance===
Addressing sustainability in existing or newly developed health facilities can be achieved through the following steps:

#'''Data''': Obtain operational performance data on your building for at least a full year. For energy, this can be obtained in the form of utility statements that indicate energy consumption in kWh.
#'''Benchmark''': The above data should be normalised so that it can be compared to benchmarks. This will indicate whether your facility is below or above benchmark performance. If performance is well over benchmark, further investigation should be carried out, as this indicates there is room for improvement.
#'''Walkthrough assessment''': A walkthrough energy assessment can be used to identify where obvious improvements can be made. Checklists are used as a basis for these assessment and they can be carried out by health facilities personnel with training or experience of the respective areas such as water and energy.
#'''Audit''': Where walkthrough assessments and benchmarking exercise indicate that a full audit is warranted this can be carried out. These audits provide detailed reports on interventions that can be carried out to improve sustainability performance in a facility.
#'''On-going operational performance''': A key component of improving sustainability operational performance, in combination with the steps above, is an on-going programme that improves performance. This includes detailed sustainability monitoring and reporting as well as day-to-day management processes required to optimise performance. Operational performance should be allocated to an individual who is required to report on this to senior management. Identified responsible persons should be provided with appropriate training, resources and incentives to achieve excellent energy performance.

==='''Sustainability integration plans'''===
The above processes can be supported through sustainability integration plans which present targets, strategies and monitoring process for each sustainability performance areas. The simplest form of this is illustrated in the table below and can be used for both design and operational processes.

Area Targets Strategy Monitoring
Sustainability performance area Sustainability targets and requirements Proposed strategy and processes Progress on achievement of targets
{| class="wikitable"
|+
!Area
!Targets
!Strategy
!Monitoring
|-
|Sustainability performance area
|Sustainability targets and requirements
|Proposed strategy and processes
|Progress on achievement of targets
|-
|
|
|
|
|-
|
|
|
|
|}



==ENERGY==

===Objective===
The building is energy efficient and uses renewable energy

===Introduction===
Energy is used in health facilities to operate equipment, heat water, and to ensure that required minimum lighting, ventilation and thermal comfort standards are met. In most existing South African building it is estimated that savings of up to 30% of energy consumption can be achieved at no or low cost. These savings can be considerably higher in new facilities were passive strategies, energy efficient equipment and renewable energy systems can be used.

Ensuring that health facilities are more energy efficient use renewable energy has a wide range of benefits including:

*Reduced carbon emissions and therefore global warming impacts

*Reduced impact of mains power outages

*Reduced negative health impacts of pollution from coal-fired power stations

*Reduced operational costs

*Improved internal environment where passive strategies such as day lighting and natural ventilation lead to improved internal conditions relative to mechanical ventilation and artificial lighting.

===Energy consumption in health facilities===
Energy in South African health facilities is largely sourced from electricity, however gas and coal may also be used in larger hospitals and some rural clinics rely on local renewable energy systems such as photovoltaic panels and solar water heaters. The proportions of energy use in a conventional South African hospital and clinic are shown in the pie charts below:
{| class="wikitable"
|+
!
!
|-
|Proportions of energy consumption in a typical South African hospital
|Proportions of energy consumption in a typical South African clinic
|}

Data on energy consumption and demand in South African facilities is not readily available. However the following table provides a number of benchmarks 1
{| class="wikitable"
|+
!Energy benchmark type
!Typical
!Good practice
|-
|Clinics
|
|
|-
|Energy consumption (kWh/m2.a)
|1
|1
|-
|Maximum demand (VA/m2)
|1
|
|-
|Renewable energy (kWh/m2.a)
|0
|
|-
|Hospitals
|
|
|-
|Energy consumption (kWh/m2.a)
|395 2
|1
|-
|Maximum demand (VA/m2)
|1
|
|-
|Renewable energy (kWh/m2.a)
|0
|
|}
 
===Design Criteria===
Highly energy efficient facilities are optimized and integrated solutions that respond closely to the local site, climate and required internal functions. It is therefore difficult to prescribe this in a set of specific design criteria; however a series of questions are outlined below which can be used to check that key energy considerations have been addressed.

===Design and operation===
Improving energy performance in health facilities requires plans, procedures and processes that ensure that sustainability is integrated effectively into design and operations of a health facility. This can be achieved through setting challenging targets and effective monitoring processes.

#Have challenging sustainability targets been set for energy?
#Have effective procedures been established to model and test performance throughout the design process to ensure that these targets are achieved?
#Have the effective monitoring and evaluation systems, including regular reporting to the client, been put in place to ensure targets are achieved?
#Have capacity and systems in the form of staffing, training, manuals, commissioning and monitoring processes been planned for and put in place to ensure that design targets are achieved in operation.

===Orientation===
Orienting facilities so that the long facades face North – South helps to reduce unwanted heat gains from low angle sunlight early in the morning and late in afternoon. Where there is no alternative but to have facades face East and West, appropriate solar shading should be provided to avoid glare and control solar heat gain.

1. Are the long facades of facilities orientated to face within 15 degrees of a North – South orientation?

2. Is glazing on West and East facades minimized?

===Building shape===
While building shape and form may generally be determined by the functions accommodated, building form can also be shaped to minimise energy consumption. Shaping built form to limit building depth (see below) ensures that interior spaces can be naturally ventilated and day lit. Built form can also direct prevailing breezes through the facilities, supporting cooling and ventilation. It can also be used to create comfortable external spaces.

#Does the form of the building respond to local climate and topography?
#Does the building shape support reduced energy consumption and help create comfortable internal and external spaces?

===Building depth===
Limiting building depth enables internal space to be day lit and naturally ventilated. This ensures that internal space may not need artificial lighting or mechanical ventilation for much of the day, reducing energy consumption.

#Are building depths less than 15m?

==='''Insulation'''===
Insulation, especially when combined with thermal mass can be used to maintain comfortable indoor conditions without significant use of mechanical equipment. Insulation can ensure that valuable heat gains from people, equipment and the sun can be retained in the building to support comfort during winter. It can also reduce unwanted heat gains from ambient conditions in summer.

#Do the building envelope U-values achieve or surpass minimum values outlined in SANS 204 (SABS 2008)?

==='''Solar shading and glazing'''===
Glazing is usually the most vulnerable area of a building envelope and high heat losses and gains can be experienced through this component. It is therefore important to design glazing and devices which enable light and heat flow to be controlled.

#Is the glazing to wall ratio compliant with SANS 204 (SABS 2008)?
#Is solar shading compliant with SANS 204 (SABS 2008)?
#Has glazing with appropriate U-values, visual transmittance and solar heat gain coefficients been selected?

===Opening areas===
Opening areas within the building envelope such as doors and windows can be used to naturally ventilate the building. In general, it is advisable to provide for openings even in facilities that are mechanically ventilated and cooled as this enables them to be occupied and used in the event of a power cut.

#Are opening areas located to support effective natural ventilation?
#Is the area of openings provided compliant with SANS 10400 XA:2011?

Air tightness

Uncontrolled infiltration and airflow through the building envelope can affect comfort and increase heating and cooling loads in the building.

#Has careful detailing and specification been used to minimise infiltration in the building.
#Has a plan for rigorous construction supervision been put in place to ensure that building envelopes are air tight?

===Mechanical systems===
As far as possible mechanical cooling, heating and ventilation should be avoided. If this is not possible, a mixed mode operation should be selected. Mixed mode operation use mechanical system when ambient and internal conditions require this, but otherwise rely on passive systems to maintain thermal comfort and meet ventilation rate requirements. In particular circumstances mechanical cooling, heating and ventilation may be required for much of the year.

#Can the building or most of the spaces be passively cooled, heated and ventilated without the requirement for mechanical systems?
#If the application of passive systems will not achieve an acceptable number of annual comfort hours, can complementary mechanical systems be introduced to meet the comfort and ventilation requirements?
#Where zones exist within a facility that are not tolerant of passive ventilation and comfort systems, can a zoned mixed mode ventilation strategy be adopted?
#Where mechanical systems have been used has a rigorous exercise been undertaken to identify the most appropriate and energy efficient system?
#Where mechanical systems have been used do these include features that help reduce energy consumption such as:

a. An economy cycle

b. Controls that enable easy systems adjustments in order to benefit for seasonal and occupancy changes.

===Equipment===
As equipment used in building can consume large amounts of energy, the energy efficiency of equipment and energy ratings should be a key consideration. In addition, controls that ensure equipment is switched off when not in use should be specified.

#Is energy efficiency a key consideration in the selection of equipment?
#Is benchmarking energy consumption or energy rating used to support the selection of equipment?
#Are the controls provided for equipment easy to use and do they ensure that equipment is off when not required?

===Internal lighting===
Ensuring adequate lighting levels may be a key consideration in many spaces within health building. This should however be achieved in the most energy efficient way. Lighting is rapidly becoming more energy efficient and there are increasingly sophisticated controls.

#Is energy efficiency a key consideration in the selection of lighting?
#Has a rigorous evaluation process, including lighting power density calculations, been undertaken to ensure that the selected lighting system is highly energy efficient?
#Have appropriately sized lighting zones (ie under 100m2) been designed to avoid lighting being on where it is not required.
#Are lighting switching arrangements easy to use and encourage users to switch off lighting when not required?
#Are motion sensors used to switch lighting off in areas such as store rooms and meeting rooms when these are not used?
#Are daylight sensors used to switch lighting off in areas where these is adequate daylight? Areas with good daylight are usually found within a zone of about 6 m from external windows.
#Can light harvesting techniques and systems be incorporated in the design solution?

===External lighting===
Concerns about security often result in highly lit external areas. While security and building access requirements must be met, external lighting should be designed to be as energy efficient as possible.

#Are only areas that specifically require external lighting included?
#Has external lighting been provided as close to the area that requires lighting as possible and directed in order to avoid losses and light pollution?
#Are photo sensors, motion sensors or timers used to ensure that lighting is only on when required?

===BMS system===
Building Management Systems (BMS) should be used in complex building with complex equipment and systems. A BMS enables different systems to integrated and controlled and can support energy efficiency

#Has a BMS been used to coordinate and integrate systems, where complex systems are used in a large building?
#Is the BMS easy to use and understand?
#Is there local training and support for the BMS>
#Is the BMS system developed to open protocols and standards?
#Does the BMS include features that support energy efficiency such as:

a. Easy access to equipment schedules so that these can easily be changed to suite occupancy patterns.

b. Reminders to ensure that BMS operator tune building systems for greatest energy efficiency. For instance the system may provide a reminder to change air conditioning set points to match seasonal changes.

c. Reporting on water and energy sub metering and related equipment schedules.

===Sub metering===
An appropriate sub-metering system enables effective energy management. A facilities manager can see how much energy is used in different areas or uses in the facility. Sub-meters also show when and how energy is used through for instance energy profiles which show energy consumption and demand over time.

#Has an energy sub metering design been developed that will monitor all of the main energy uses in the facility?
#Is energy management data provided in formats and reports that can be easily understood and analyzed to support improved energy management?
#Does the system provide energy management report that can be used by both facilities managers and senior managers to improve energy efficiency in the facility?

===Renewable energy===
Increasingly renewable energy is becoming a competitive alterative to ESKOM supplied power. It also has the advantage that it increases the energy autonomy and independence of facilities, allowing these to operate even when there are mains power cuts.

#Are solar water heaters used to heat water in the facility?
#In areas with high quality, reliable sunlight, are photovoltaic systems used to reduce the reliance on ESKOM power?
#In areas with high quality, reliable wind, are wind turbines used to supplement to reduce the reliance on ESKOM power?

==WATER==

===Objective===
The building minimises the consumption of mains potable water.

===Introduction===
Water is used in health facilities for cleaning equipment, utensils and facilities, laundry, irrigation, food preparation and for drinking. In most existing South African health facility it is possible to reduce mains potable water consumption at no or low cost. These savings can be considerably higher in new facilities where water efficient technologies, grey water and rainwater systems can be used.

Ensuring that health facilities are more water efficient has a wide range of benefits including:

*Reduced water consumption and associated negative environmental impacts
*Reduced impact of mains water shortages or outages
*Reduced operational costs

===Water consumption in health facilities===
Water in South African health facilities is largely sourced from municipal potable water supply, however in some areas water may come from a rain water tanks or a borehole. The proportions of water use in a conventional South African hospital and clinic are shown in the pie charts below:
{| class="wikitable"
|+
!
!
|-
|Proportions of water consumption in a typical South African hospital
|Proportions of water consumption in a typical South African clinic
|}



Data on energy consumption and demand in South African facilities is not readily available. However the following table provides a number of benchmarks 1
{| class="wikitable"
|+
!Water benchmark type
!Typical
!Good practice
|-
|Clinics
|
|
|-
|Water consumption (kl/m2.a)
|1
|1
|-
|Hospitals
|
|
|-
|Water consumption (kl/m2.a)
|70 2
|1
|}
 

===Criteria===
The consumption of mains potable water in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective performance requirements within the health facility; however a series of questions can be used to check that key water considerations have been addressed. These are outlined below.

===Wash Hand Basin Taps===
Controlling and reducing water flows in wash hand basin taps can be used to reduce water consumption.

#Are wash-hand basin tap flow rates should not exceed 6L/minutes?
#Are passive infra-red (PIRs) or push-button controls used to limit the duration of flows?
#Has legionella control been considered when designing for low flow and systems and where existing system are made redundant?

===Toilets===
Reducing flush rates in water-borne sanitation can be used to reduce water consumption.

#Have WC flush rates been specified that do not exceed 6L/flush?
#Have dual flush controls can be used to ensure that reduced flush rates can be used when full flushes are not required?

===Showerheads===
Controlling and reducing water flows in showers can be used to reduce water consumption. The following measures can be considered:

#Have shower head flow rates been specified to not exceed 10L/minute?
#Are push-button type controls used to limit the duration of flows?
#Has legionella control been considered when designing for low flow and systems and where existing system are made redundant?

===Irrigation===
Minimizing irrigation water requirements can be used to reduce water consumption. The following measures can be considered:

#Are locally indigenous species (species found in the local area) used to minimise irrigation requirements?
#If irrigation is required, are highly efficient water delivery systems, such as a drip irrigation linked to soil moisture probes, used to minimise irrigation requirements.
#Has grey water been used to avoid the use of potable water for irrigation?

===Grey water systems===
Grey water systems reduce mains potable water consumption by reusing lower quality water within the facility. Examples of this are where waste water from showers and wash hand basins is captured and reused to flush toilets. Other sources of grey water include waste water from laundries and HVAC systems. Grey water systems however are potentially hazardous to human health, particularly in health facility environments. In particular, grey water which is left to stand for over 36 hours or is contaminated by food or similar waste is considered as blackwater and requires the same treatment as sewage. Therefore, grey water systems should only be designed, implemented and operated by appropriately competent people. Potential grey water applications in health facility environments are described below:

*Wash hand basin and shower waste water: Waste water from wash hand basins and showers can be directed to a grey water system and then used to flush toilets or for landscape irrigation.
*Vehicle wash: Waste water from vehicle waste can be reused to wash vehicles for up to 3 or 4 times. After this it can be disposed of or used for irrigation.
*HVAC plant: It may be possible to use waste water from HVAC systems for irrigation or to flush toilets. To ascertain if this is possible investigations should be carried out with the HVAC manufacturer and grey water specialists.

The following considerations in relation to grey water systems should be made:

*Have significant sources of grey water from, for instance, showers and wash-hand basins, been captured in a grey water system?
*Are grey water usage points appropriately labelled to prevent unsafe consumption.
*Will this grey water be used for irrigation or to flush toilets in order to significantly reduce portable water consumption?
*Is the proposed grey water system easy and cost effective to maintain?
*Have as many of the potential health hazards associated with the system been eliminated?

===Rain water systems===
Rain water systems store water captured from roofs or hard landscape surfaces. This water is then available for irrigation, to flush toilets or for cleaning. In large facilities very substantial amounts of water can be captured and used to reduce mains potable water consumption. A number of different types of systems are described below:

*Roof rainwater harvesting: Rainwater from roofs is directed to tanks and stores. Usually a proportion of initial run-off is directed to waste as it may have picked up dust and other debris. This system is the most common and generally has the lowest cost as rainwater tanks can be installed above ground surface.
*Hard surface rain water: This system captures storm water run-off from hard surfaces such as game pitches, paths and car parking. This type of system generally requires some form of filtration to remove debris, and in the case of car parking, oil wastes. Tanks are usually sub-surface.
*Landscape surface run-off capture: Surface run-off from soft landscaping can be captured and reused. This is sometimes used as part of an onsite storm water retention strategy. The disadvantage of this system is that the resulting water quality can be poor as debris and silt may be picked up. The filtration and maintenance requirements are therefore more stringent.

The following considerations in relation to rain water systems should be made:

#Have significant sources of rain water from roof and hard surfaces been captured in a rainwater harvesting system?
#Will this rain water be used in functions such as irrigation or to flush toilets in order to significantly reduce portable water consumption?
#Is the proposed rainwater harvesting system easy and cost effective to maintain? Have as many of the potential health hazards associated with the system been eliminated?

==WASTE==

===Objective===
The building minimizes waste directed to landfills.

===Introduction===
Waste in South African health facilities is largely directed to landfill sites. Not only does this use up valuable land, but can also lead to air, soil and water pollution if not waste is not disposed of correctly. In addition, this waste also consists of valuable resources that could be easily reused and recycled. Recycling and reusing materials not only reduces energy and resource consumption but can also create jobs and additional revenue streams.

Ensuring that health facilities minimise waste and reuse and recycle waste products are as follows:

#Reduced loss of land area to landfill
#Reduced energy and resource consumption
#Potential to create jobs and small enterprises

===Waste production in health facilities===
Waste in South African health facilities is largely directed to landfill sites. However in some area waste may be disposed of by local recyclers. The proportions of waste generated use in a conventional South African hospital and clinic are shown in the pie charts below:
{| class="wikitable"
|+
!
!
|-
|Proportions of waste in a typical South African hospital
|Proportions of waste in a typical South African clinic
|}

Data on waste in South African facilities is not readily available. However the following table provides a number of benchmarks 1
{| class="wikitable"
|+
!Waste benchmark type
!Typical
!Good practice
|-
|Clinics
|
|
|-
|Waste production (kg/m2.a)
|1
|1
|-
|Proportion of waste recycled or reused
|10%
|
|-
|Hospitals
|
|
|-
|Waste production (kg/m2.a)
|1
|1
|-
|Proportion of waste recycled or reused
|10%
|
|}

===Criteria===
Waste in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that key waste considerations have been addressed. These are outlined below.

===Provision for recycling===
Recycling can be encouraged by developing systems that make this easy. This includes providing easy-to-use receptacles for different types of waste and providing space in the right locations so that waste can be stockpiled into worthwhile quantities for a recycler to collect.

#Are there appropriate waste receptacles at the waste source to enable waste to be disposed of easily?
#Are there adequate number and type of waste receptacles at source to ensure that the value of waste is not reduced as a result of wastage or mixing of waste? For instance, clean waste paper can be spoilt if mixed with food waste.
#Has adequate storage space been provided in an appropriate location for the different recycling waste streams so that this waste can be stockpiled and easily accessed recycling contractors?

===Engagement with local recyclers===
Engaging with local recyclers earlier in the development of a new or refurbished facility can be used to understand the recycling process and the key requirements to make this effective.

#Have all the potential waste streams been identified? These include paper, cardboard, tin, glass, plastic, timber, electrical appliances etc?
#Have appropriate associations and local recyclers related to each of these waste streams been engaged with a view to ensuring that appropriate provision and systems are put in place to maximised recycling.

===Engagement with suppliers===
Engaging with suppliers can be used to reduce waste and transportation impacts. Waste and transportation impacts can be reduced through reduced use of packaging, use of reusable containers and optimized logistic supply chains.

#Have all suppliers of substantial goods and services to the health facilities been identified? Have these been engaged in relation to transportation and packaging with a view to minimising impacts in these areas?
#Has provision been made to reduce packaging waste and transport impacts through aspects such as increased space allowances for releasable containers and storage of products?

===Construction waste===
Construction is a major source of landfill waste. Waste from construction however can usually be easily reduced through explicit planning and monitoring processes.

#Has was construction waste minimization and recycling been included as specific requirement within tender and contract documents?
#Has the contractor been asked to develop a construction waste management plan in order to minimise waste? Does this plan include specific construction waste management targets ie 50% of all waste on site will be recycled? Have the parties responsible for implementing the plan been identified clearly and have they been given the mandate and resources to implement the plan? Has an appropriate monitoring and evaluation systems been put in place to ensure targets are achieved?

==MATERIALS==

===Objective===
Construction impacts of building are minimized

===Introduction===
Materials used in new facilities and the refurbishment of facilities can have significant impacts. Materials may be mined, processed, manufactured and transported before being incorporated in facilities. The extent and nature of the impacts of these stages varies widely depending on the material. The selection of materials and products to be used in facilities therefore is important in reducing negative environmental impacts.

Careful selection of construction materials used in health facilities has the following benefits:

*Reduced land and mining impacts
*Reduced environmental and health impacts from manufacturing processes
*Reduced transportation impacts
*Reduced material use
*Increased use of local sustainable materials

===Material use in health facilities===
Materials are used to construct South African health facilities and largely found in the building structure and envelope. More specialist materials and products such as refrigerants are found in equipment and systems within the building. The source and processes associated with construction materials and products have a wide range of impacts. It is therefore important to understand and confirm these with respective suppliers in order to select and specify materials and components with the least negative impacts.

===Criteria===
Material and component selection in health facilities can be addressed developing criteria list, communicating this to suppliers, and using this as a basis for specification and design. The nature of these criteria will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that key material and component considerations have been addressed. These are outlined below.

===Building reuse===
Using existing facilities instead of building new avoids or reduces the requirements for construction materials and therefore the impacts associated with extracting, manufacturing and transporting these. In addition, existing facilities are usually part of the urban fabric and already serviced with electricity, water, roads and public transport. Increasing the intensity of use of this fabric increases its efficiency and avoids the requirement to replicate this elsewhere. Therefore, in most circumstances it is preferable to reuse and refurbish existing facilities rather than build new facilities.

#Can the existing facilities continue to be used? If necessary, can these be refurbished and expanded rather than building a new facility?
#Are there other existing facilities that can be used? Can these be readily adapted for health use rather than constructing new facilities?

===Contribution to Global Warming===
Construction materials can contribute to global warming through carbon emissions associated with large amounts of energy used in their extraction, processing and transportation. This is referred to as embodied energy. Other materials such as refrigerant can contribute directly to global warming if they are released or leak into the atmosphere. Using existing facilities instead of building new avoids or reduces the requirements for construction materials and therefore the impacts associated with extracting, manufacturing and transporting these. In addition, existing facilities are usually part of the urban fabric and already serviced with electricity, water, roads and public transport. Increasing the intensity of use of this fabric increases its efficiency and avoids the requirement to replicate this elsewhere. Therefore, in most circumstances it is preferable to reuse and refurbish existing facilities rather than build new facilities.

#Refrigerants: Where refrigerants are being used in HVAC systems, cold rooms or in fire suppressions sytems have refrigerants with the lowest Global Warming Potential (GWP) and Ozone Depleting Potential (ODP) impacts been selected?
#High embodied energy materials: As far as possible, have construction materials with low embodied energy such as timber been selected? Where it is not possible to use these type of materials and high embodied energy materials such as cement and aluminium have to be use have the quantities of these materials been minimised?

===Reused materials or materials with recycled content===
Construction materials that are reused or have recycled content have less energy associated with their manufacture than equivalent new materials. Where possible, it is therefore preferable to reuse materials that may have already been used in another building or to select materials with recycled content.

#Are there materials from another building that is being demolished that could be reused? Aspects that can be reused include structure steel elements, facades, demountable structures such as carports, and building components such as windows and doors. Crushed concrete from demolished structures can also be used as aggregate in new construction.
#Have materials with recycled content been specified in preference to materials without any recycled content? Can the supplier / manufacture confirm the reduced environmental impacts of their recycled content product relative to new products?

===Reduced material use===
The quantity of construction materials used in facilities can be reduced through avoiding material use, using materials more intelligently and using materials for more than one use.

#Avoided material use: Have materials been avoided where these are not required? For instance, can ceilings and plastering be avoided through better concrete finishes? Can improved floor finishes be used to avoid the requirement for carpets and tiling? Can the use of passive systems reduce the requirement for ducting and plant?
#Intelligent material use: Can quantities of materials be reduced through different designs and specifications? For instance, can structural strategies such as pre-tensioning concrete slabs and waffle slabs be used to reduce concrete requirements? Can material use and wastage be reduced through use of precast elements?
#Dual plus use: Can materials be used for more than one purpose? For instance, can photovoltaic panels be used as a roofing material as well as to generate material?

===Material source===
The quantity of construction materials used in facilities can be reduced through avoiding material use, using materials more intelligently and using materials for more than one use.

#Avoided material use: Have materials been avoided where these are not required? For instance, can ceilings and plastering be avoided through better concrete finishes? Can improved floor finishes be used to avoid the requirement for carpets and tiling? Can the use of passive systems reduce the requirement for ducting and plant?
#Intelligent material use: Can quantities of materials be reduced through different designs and specifications? For instance, can structural strategies such as pre-tensioning concrete slabs and waffle slabs be used to reduce concrete requirements? Can material use and wastage be reduced through use of precast elements?
#Dual plus use: Can materials be used for more than one purpose? For instance, can photovoltaic panels be used as a roofing material as well as to generate material?

===Sustainable sources===
Materials can be defined in terms of whether they are from sustainable or non-sustainable sources. Materials from sustainable sources include timber, cork, wool that are grown and therefore can be harvested on an on-going materials. Other materials such as plastics and metals are mined and therefore once these sources are depleted will not be available.

#Where possible, have materials from sustainable sources been specified? For example, have timber, and plant-based products been used in preference to materials that have to be mined and processed?
#Are materials from sustainable sources actually being grown and harvested on a sustainable on-going basis? For instance, has timber specified been certified by the Forest Stewardship Council (FSC) as being from a sustainable source? It is important to note that there are still timber products available, in particular hardwoods, that are harvested from tropical rainforests which are not being replanted and therefore are not considered sustainable sources.

===BIODIVERSITY===

===Objective===
The building supports biodiversity

===Introduction===
Biodiversity plays a very important role for man through providing ecosystem services. Ecosystem services include the production of food and water, the control of climate and disease, supporting nutrient cycles and crop pollination and spiritual and recreational benefits.

Ensuring that health facilities take into account biodiversity has a wide range of benefits including:

*Maintaining local ecosystem services
*Providing an natural amenity such as gardens which would could support recuperation.

===Biodiversity in health facilities===
Health facilities affect biodiversity through their location and in the way that site planning and landscaping is carried out. New facilities can minimise negative impacts on biodiversity by avoiding green field sites and building outside municipal boundaries. Biodiversity within health facility sites can be supported through considered site planning and landscaping strategies.

===Criteria===
Biodiversity in health facilities can be addressed in a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key biodiversity considerations have been addressed. These are outlined below.

===Site location===
Biodiversity is being lost at a rapid rate through urban sprawl. Preserving existing biodiversity can therefore be achieved by avoiding green field site and building only within urban boundaries.

#Has the health facility been planned for a brown field (already built-on) sites?
#Has the health facility been planned for a location within an urban boundary so that this does not take up land that supports agriculture and or biodiversity.

===Design for biodiversity===
Biodiversity can be supported through site layouts and landscaping that retains existing biodiversity and enhances this.

#Has planning of the health facility ensured that existing valuable biodiversity on site is preserved?
#Have valuable links and wildlife corridors between biodiversity on the health facility and adjacent sites been preserved?
#Has the landscaping strategy enhanced existing biodiversity? Does this include the introduction of appropriate loc

==TRANSPORT==

===Objective===
The building supports energy efficient transportation

===Introduction===
Ensuring that health facilities support energy efficient transportation has a wide range of benefits including:

*Reduced air pollution and noise from vehicles
*Health benefits from increased opportunities for exercise
*More affordable transport for health facility users
*Reduced space requirements as a result of reduced parking and road requirements.

===Transportation in health facilities===
Transportation is important in health facilities as large numbers of people and goods need access to these facilities everyday. This includes health facilities staff who commute and health facilities users. The right location and provision of facilities help ensure that the transport impacts associated with this access is minimized and potential health benefits such as exercise are supported.

===Criteria===
The transportation in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that transportation considerations have been addressed. These are outlined below.

===Access to public transport===
Locating health facilities near public transport facilities and enabling good access to these encourage people to use these in preference to personal vehicles. The use of public transport can be encouraged by ensuring that health facilities are located near well used public transport nodes and that there are good walking routes between these and key locations within the health facility.

#Is the health facilities located near good public transport nodes such as minibuses, buses, trains and bus rapid transport systems?
#Are there safe, direct and easy-to-use routes between public transport nodes and key locations within the health facility? (see also provision for walking criteria)

===Provision for walking===
Making provision that encourages walking helps to ensure that people walk to health facilities instead of using vehicles. Walking can be encouraged through safe, direct and easy-to-use routes.

#Are there safe direct pedestrian routes to and around the health facilities site from neighboring areas and public transport nodes? (see also criteria 4 for detail)
#Are there safe direct pedestrian routes from neighboring areas to key locations within the health facility such as the main reception? (see also criteria 4 for detail)
#Are there safe direct pedestrian routes within the health facilities between all locations within the health facility? (see also criteria 4 for detail)
#Does pedestrian provision include safe road crossings such as bridges, underpasses and zebra crossings? Are routes wide enough and have appropriate finishes and other required characteristics to enable them to be easily used by people with disabilities and by predicted pedestrian numbers? Are routes safe and benefit from visual supervision by surrounding facilities and other pedestrians? Have lighting and appropriate security safety mechanisms been put in place if routes will be used at night?

===Provision for cycling===
Making provision that encourages cycling helps to ensure that people cycle to health facilities instead of using motorized vehicles. Cycling can be encouraged by providing secure cycle storage, changing or showering facilities and safe, easy-to-use local routes.

#Are there safe direct cycle routes to and around the health facilities site from neighboring areas? (see also criteria 4 for detail)
#Are there safe direct cycle routes from neighboring areas to key locations within the health facility such as the main reception? (see also criteria 4 below for detail)
#Are there safe direct cycle routes within the health facilities between all locations within the health facility? (see also criteria 4 for detail)
#Does this cycle provision include designated, separate routes and safe road crossings and junctions? Are routes wide enough and have appropriate finishes and other required characteristics to enable them to be easily used by predicted numbers of cyclists? Are routes safe and benefit from visual supervision by surrounding facilities and other cyclists? Have lighting and appropriate security safety mechanisms been put in place if routes will be used at night?

==RESOURCE USE==

===Objective===
The building makes efficient use of resources

===Introduction===
There are limited resources in the form of land, finance and raw materials to construct and maintain facilities. It is therefore important to use these resourced carefully. Benefits associated with careful resource use include:

*Avoiding waste
*Ensuring effective and efficient use of resources
*Ensuring that resources are available for other uses where these are not required

===Resource use in health facilities===
Health facilities use financial resources to enable construction and maintenance. They also consume materials and energy in their construction. Finally health facilities use land. Careful use of these resources enables waste to be avoided and these resources to be available for other uses where this is required.

===Criteria===
Resource in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that key resource considerations have been addressed. These are outlined below.

===Site density===
Detailed long term strategic plans for health facilities should be developed that take into account future projections. These should ensure that expansion or changes that are envisaged can be accommodated. However care should be taken that unnecessarily large areas are allocated for health facilities to avoid land being unused.

#Has a long term strategic site plan been developed for the health facility that addresses changes that may occur in the future, such as expansion or contraction?
#Has the over allocation of space for health facility sites been avoided?

===Occupancy density===
Robust sustainable facilities accommodate change through flexible and adaptable allocation and configuration of space. While this is important over provision of space should be avoided as this space will need to be serviced and maintained even if it is not used. Health facilities should therefore be designed to support spatial efficiency and effective use.

#Is the overall space allowance in the health facility in line or below health facilities norms, for instance, in terms of gross area per bed?
#Are the proportions of spaces use in the health facility in line with good practice health facilities design? For instance is the space allocated for circulation, support and ancillary services as a proportion of the total area in line with best practice norms?

===Food production===
Food production in the form of orchards or vegetable gardens are a productive way of using land that leads to both environmental and health benefits. Where land is available in health facility sites and there is water and appropriate capacity, food production should be encouraged and produce made available to be consumed within the health facility or by local communities.

#Has available land within the health facility site been developed for local food production?
#Has appropriate provision in the form of irrigation, fencing, organizational and capacity requirements been made to ensure that food production will be effective and sustained?

==MANAGEMENT==

===Objective===
The building is managed to support sustainability

===Introduction===
Facilities can be designed to support effective management. Systems can also be developed to ensure that facilities are effectively and efficiently used and maintained. In health facilities this is particularly important because of the stringent environmental requirements for health care and the high operating costs of the facility.

Ensuring that health facilities are effectively managed has a wide range of benefits including:

*Ensuring that operating costs are controlled and reduced
*Minimising disruption to health care as result of maintained and repairs
*Ensuring that maintenance is planned for and effective carried out

===Building management in health facilities===
Building management aims to ensure that health facilities are effectively operated and maintained in order to support healthcare services that they accommodate. Personnel with appropriate capacity, mandate and resources should be allocated to this function.

===Criteria===
Building management in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that building management considerations have been addressed. These are outlined below.

===Energy and water sub metering===
Energy and water sub metering enables the manager of a health facility to manage the consumption of energy and water and reduce costs associated with these services.

#Has energy sub metering been installed which enables energy consumption in all areas with substantial loads to be measured and monitored? Do energy meters support assessment of energy consumption trends, profiles and comparison with benchmarks?
#Has water sub metering been installed which enables water consumption in all areas with substantial consumption to be measured and monitored? Do water meters support assessment of water consumption trends, profiles and comparison with benchmarks?
#Is water and energy consumption monitored and reported to senior management on a regular basis?

===Facilities management manual===
A facilities management manual provides technical detail on all aspects of the building and how they should be maintained and managed. It is useful because it provides a repository of knowledge and information that can be used by facilities managers and their staff to ensure that health facilities are effectively managed and maintained.

#Has a detailed facilities management manual been developed for the health facilities? Does this include a detailed schedule for maintenance and other checks on equipment such as lighting, pluming fittings and HVAC
#Does the facilities management manual refer to a full set of as-built drawings and equipment manuals? Have a full set of hard copy and electronic copy as-built drawings and manuals been provided?
#Have facilities managers in the building had a full induction on the building’s systems and the facilities management manual?
#Does the facilities management manual get regularly reviewed and updated to reflect upgrade and renovations details.

===Senior management commitment===
Effective management of facilities can be supported by senior management commitment. Regular reporting on facilities performance such as energy and water consumption serve to ensure that management is aware of these issues and are likely to ensure that the appropriate mandate and resources are in place to improve this.

#Have facilities management policies in relation to sustainability been developed? For instance, are there policies or guidance on how energy and water consumption will monitored and managed?
#Have facilities management policies or guidelines been endorsed by senior management? Is there are requirement for facilities management to report on facilities performance on a regular basis to senior management?

==LOCAL ECONOMY==

===Objective===
The building supports the local economy

===Introduction===
The construction and maintenance health facilities are a significant investment by government. This investment, if considered carefully, can be used to support the local economy and employment. This is done by specifying local products and services from the local area.

Ensuring that health facilities support the local economy has a wide range of benefits including:

*Increased local employment
*Increased local capacity for new construction and maintenance of facilities

===Local economy in health facilities===
Supporting the local economy can be achieved in new facilities by understanding the nature and type of local building product suppliers and where appropriate specifying these in the building. Similarly understanding the capacity and skills of local contractors can be used to ensure that these are developed and enhanced by being engaged in the construction and maintenance of health facilities.

===Criteria===
Supporting the local economy in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key waste considerations have been addressed. These are outlined below.

===Small enterprise support===
The waste and emissions in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key waste considerations have been addressed. These are outlined below.

Minimizing irrigation water requirements can be used to reduce water consumption. The following measures can be considered:

#Are small enterprises provided with opportunities to tender for relevant construction and maintenance contracts? Can local, small enterprises be given preference in the awarding of work?
#Where local small enterprises have limited capacity and experience, can they be supported by encouraging partnerships with more established and larger enterprises?

===Material and component procurement===
The specification of local materials and components in the construction of health facilities can provide a significant incentive to local suppliers and manufacturer to develop appropriate products and capacity. This in turn provides local employment and can ensure that maintenance and repairs at the facilities can be carried out more quickly and cost effectively.

#Has a review of local materials and components been carried out?
#Have local materials and components been specified?

===Construction employment===
The construction industry can employ significant numbers of people. This can be supported through designs, specifications and labour intensive construction techniques which can be used to construct facilities without significant cost or time implications. Local construction employment improves the local economic impact of projects and ensures that there is local capacity to undertake repairs and maintenance of facilities.

#Is construction employment a key consideration in the design, specification and construction of the facility?
#Have opportunities to create local employment been sought and developed through the project?

==PRODUCTS AND SERVICES==

===Objective===
The building supports use of more sustainable products and services

===Introduction===
Products and services used in health facilities have a range of impacts and planning can be used to maximise beneficial impacts and avoid negative impacts. The construction and maintenance health facilities are a significant investment by government. This investment, if considered carefully, can be used to support the local economy and employment. This is done by specifying local products and services from the local area.

Ensuring that health facilities support the more sustainable products and services has a wide range of benefits including:

*Reduced waste
*Increased support for sustainable choices and options for health facility users

===Products and services in health facilities===
Supporting the local economy can be achieved in new facilities by understanding the nature and type of local building product suppliers and where appropriate specifying these in the building. Similarly understanding the capacity and skills of local contractors can be used to ensure that these are developed and enhanced by being engaged in the construction and maintenance of health facilities.

===Criteria===
Supporting the more sustainable products and services in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key product and service considerations have been addressed. These are outlined below.

===Local produce===
Impacts associated with transport and storage / refrigeration mean that produce imported from some distance away generally has significantly higher ecological footprints than local produce. Health facilities can therefore reduce ecological footprints associated with food through using local produce as far as possible.

#Is local produce used in preference to produce imported some distance away?
#Has the use of local produce been made a requirement in outsourced catering contracts?

===Vegetarian options===
Meat-based meals generally have significantly higher ecological food print requirements relative to vegetarian meals. Providing vegetarian options can therefore support reduced food impacts within health facilities.

#Are vegetarian options provided in catering establishments within the health facility?
#Has the provision of vegetarian options been made a requirement for outsourced catering contracts?

===Drinking water===
Waste streams can be reduced by providing alternatives to bottled drinking water. Drinking water can be provided through strategically located drinking fountains, as well as being supplied in reusable containers. A ready supply of drinking water also has health benefits.

#Is non-bottled drinking water readily and freely available throughout the health facility?

===Reuseable vessels===
Significant waste streams can be avoided through the use of reusable vessels. In particular disposable food and drink vessels can be avoided by providing reusable vessels. This option can be supported through provision of required storage and washing and facilities.

#Have reusable vessels been specified in preference to disposable containers, for services such as catering?
#Has adequate provision been made for reusable vessels in the form of storage and washing facilities?

==ACCESS==

===Objective===
The building supports access to facilities

===Introduction===
Current work patterns and lifestyles mean that many people have to access facilities such as banking, retail, childcare and communications on a regular basis. Ensuring that these facilities are within the health facility or within easy walking distance helps to avoid or reduce associated time and transport impacts.

Ensuring that health facilities support access to facilities has a wide range of benefits including:

*Reduced transport impacts
*Reduced time spent travelling to and from facilities

===Access to facilities in health facilities===
Supporting access to local facilities can be achieved through incorporating these into the health facility. Alternatively the health facility can be located near where these exist. It may also be possible to work with relevant service providers in order to provide these locally.

===Criteria===
Supporting access to facilities in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key access considerations have been addressed. These are outlined below.

===Banking===
Access to banking can be provided through formal banking facilities or through bank ATMs. This can be provided within the health facility or within easy walking distance of this.

#Are banking facilities available within the health facilities or within the local area?

===Grocery retail===
Grocery retail can be provided through local shops, supermarkets and markets. This can be provided within the health facility or within easy walking distance of this.

#Are grocery retail facilities available within the health facility or within the local area?

===Communication===
Access to telephone and internet can be provided through internet cafes or at stand alone kiosks. This can be provided within the health facility or within easy walking distance of this.

#Are internet and telephone facilities available within the health facility or in the local area?

===Café===
Access to catering facilities can be provided through cafes, restaurants or canteens. Refreshments should be affordable and accessible to both staff and health facility users. This can be provided within the health facility or within easy walking distance of this.
1. Is there an accessible, affordable café, restaurant or canteen within the health facility or in the local area?

===Childcare===
Significant waste streams can be avoided through the use of reusable vessels. In particular disposable food and drink vessels can be avoided by providing reusable vessels. This option can be supported through provision of required storage and washing and facilities.

#Is there a childcare facility within the health facility or in the local area?

==HEALTH==

===Objective===
The building supports a healthy and productive environment

===Introduction===
Health facilities by their definition aim to support health and well being in their users. In addition to medical care health can be promoted through beneficial environmental conditions including a plentiful supply of fresh air, views and optimum thermal comfort conditions. It is particularly important to avoid conditions and situations that may be harmful to human health.
Ensuring that health facilities support the health in facility users and construction workers services has a wide range of benefits including:

*Improved recovery rates for patients
*Reduced absenteeism associated with environmental conditions by health facility staff
*Reduce injury and absenteeism rates associated with dangerous or harmful working construction environments

===Criteria===
Ensuring construction and health facilities promote health can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that health promotion considerations have been addressed. These are outlined below.

===External views===
Views and a connection to the external environment improve internal environmental conditions and can help improve recovery rates and reduce employee absenteeism.

#Do health facility staff working areas have views to the external environment
#Do patient areas have views of the external environment?

===Daylight===
Day lighting can help reduce energy consumption associated with artificial lighting. It also improves internal environmental conditions for patients and health facility employees.

#Are health facility staff working areas well day lit?
#Are patient areas well day lit?

===Ventilation===
High levels of fresh air are important for human health and productivity. This can be provided through natural or mechanical ventilation. Where mechanical ventilation is used sufficiently high levels of external, fresh air should be provided and recirculated air should be avoided or minimized.

#If the condition of outside air makes it unfit for direct ventilation use, is it appropriately pre-treated and filtered by the ventilation system?
#Are health facility staff working areas well supplied with good quality outside air?
#Are patient areas well supplied with good quality outside air?

===Building materials===
Building materials can have negative impacts for human health associated with their extraction and manufacture. They may affect health in facilities, through for instance offgassing hazardous chemicals. Construction materials should therefore be screened to avoid products being used in health facilities that have negative impacts on human health.

#Has criteria been developed and applied for the selection and screening of building materials?
#Have all building materials that may off gas substances such as formaldehyde and volatiles organic components that may be harmful to human health been avoided?

===Contractor health and safety===
There are considerable health and safety risks in the construction industry. Considering health and safety in the design of health facilities can be used to reduce health and safety risks associated with construction and maintenance. Making provision for safe access to glass facades or to high level lighting helps to ensure that this can be installed, cleaned and maintained without undue health and safety risks. In addition, addressing health and safety comprehensively in contract and construction planning, procedures and processes can be used to eliminate many construction health and safety risks.

#Has contractor health and safety been considered as a key issue in the design of the building? Have construction risks been minimised through appropriate design risk assessments and mitigation?
#Have detailed construction plans, procedures and processes been developed to minimise risks where these may occur during construction?
#Has appropriate health and safety procedures been put in place to ensure that plans are implemented and monitored?

==EDUCATION==

===Objective===
The building supports education

===Introduction===
Education and on-going learning is increasingly been seen as an essential component of sustainable development and a competitive economy. This is recognised in health care through the requirement for health care professionals to under continued professional development (CPD). Education and on-going learning can be supported through technology and spaces within facilities that support this. Examples of this include training rooms and access to ICT and reading material. In addition well packaged
Ensuring that health facilities support the education has a wide range of benefits including:

*Improve ability by health facilities staff to keep up-to-date with new developments in health care
*Ability to attract and retain staff

===Criteria===
Ensuring construction and health facilities promote education and on-going learning can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that education and on-going learning considerations have been addressed. These are outlined below.

===Contractor education===
There are considerable health and safety risks in the construction industry. Considering health and safety in the design of health facilities can be used to reduce health and safety risks associated with construction and maintenance. Making provision for safe access to glass facades or to high level lighting helps to ensure that this can be installed, cleaned and maintained without undue health and safety risks. In addition, addressing health and safety comprehensively in contract and construction planning, procedures and processes can be used to eliminate many construction health and safety risks.

#Has contractor health and safety been considered as a key issue in the design of the building? Have construction risks been minimised through appropriate design risk assessments and mitigation?
#Have detailed construction plans, procedures and processes been developed to minimise risks where these may occur during construction?
#Has appropriate health and safety procedures been put in place to ensure that plans are implemented and monitored?

===Notice boards===
Notices are very easy and cost effective way of communicating information. They can be used to support education and awareness by drawing attention to new or important education. For instance, awareness and reminders about new health care policy, procedures and processes can be communicated. Notice boards have the benefit that they can be located where they will be seen by all personnel on a regular basis and are not reliant on a particular technology, such as email. This helps to ensure information can be communicated to all levels of staff within a health facility.

#Have notice boards been located in key locations in the health facility where they can be used to communicate key information to facility staff and users?
#Have communication and education plans been developed that will ensure that notice boards will be updated throughout the year with relevant notices and information?

===Space for learning===
Formal training can be supported through access to training rooms. More informal on-going learning can be provided through access to resource centres where learning material, computers and the internet can be accessed.

#Are there appropriately sized and equipped facilities to accommodate formal training?
#Are there appropriately sized and equipped facilities to support informal on-going learning by staff?

===Employee induction===
Employee induction refers to awareness training provided to new employees. This can be used to support sustainability by developing awareness in health facility staff about sustainable building systems and how they should be used. This may include aspects such as lighting and HVAC operation as well as recycling procedures.

*Have employee induction processes been developed?
*Do these include detailed information on systems in the building that aim to support sustainability?

===Building user manual===
Building user manuals aim to complement employee induction processes by providing easily accessible and understanding information related to a facility in order to support user behaviour that support sustainability.

#Has a building user manual been developed?
#Is this readily accessible and easy to use?

==INCLUSION==

===Objective===
The building is inclusive of diversity in population

===Introduction===
Design for inclusion helps to ensure that facilities can be used by all users including older people, sick people, people with children and people with disabilities. Inclusive design also often means that facilities are safer and easier to use. In health facilities both of these aspects are particularly important.

Ensuring that health facilities are inclusive has a wide range of benefits including:

*Less requirement to replicate facilities
*Facilities that are easier and safer to use

===Criteria===
Ensuring health facilities are inclusive can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key inclusion considerations have been addressed. These are outlined below.

===Accessible transport===
Inclusive access to health facilities is an important consideration. This means ensuring that people who may be ill, infirm, old or have disabilities are able to access health facilities easily. This requires accessible routes from places for work and accommodation to the facilities and often requires easily accessible local public transport systems. This can be p

Ensuring that health facilities support the education has a wide range of benefits including:

#Are there regular, affordable and efficient local transport systems?
#Can these be accessed readily from health facility users’ accommodation and places of work?
#Can the health facility be accessed readily from public transport?
#Is public transport provision inclusive?

===Environmental access===
Facility design and management for environmental access can be used to ensure that health facilities are inclusive. This requires a comprehensive approach that ensures that access consideration are effectively integrated into all aspects of health facility design. Guidance on this aspect is provided in the IUSS d

#Does the facility design fully comply with the IUSS environmental access requirements?
#Are systems and management in place to ensure that environmental access standards are maintained during operation?

===Access to affordable accommodation===
There is an increasing shortage of affordable accommodation in many South African cities. This can have a range of negative impacts including the requirement for long distance commuting, disrupted family life, and reduced family budgets for non-transport related costs such as education and health. Increasing local affordable accommodation can be achieved through partnership agreements with local developers and social housing organizations.

#Is there affordable local accommodation for health facility staff?
#If this does not exist, have initiative been taken to develop this with developers and or social housing institutions?

==SOCIAL COHESION==

===Objective===
The building supports social cohesion

===Introduction===
Social cohesion refers to the extent to which individuals within a community understand, collaborate, trust and work together. It is valuable because it enables collective knowledge and resources to be used more effectively and efficiently to support common goals. Within a health facility improved social cohesion can support improved healthcare with fewer resources by sharing and using these more effectively. It can also support improved communication and cooperation within health teams and therefore improving levels of service and reducing wastage and mistakes.

Ensuring that health facilities support social cohesion has a wide range of benefits including:

*More efficient and effective use of resources
*Improved communication and coordination
*Reduced wastage

===Criteria===
Ensuring health facilities support social cohesion can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key social cohesion considerations have been addressed. These are outlined below.

===Shared used of facilities===
Shared use of facilities helps to ensure that valuable facilities are well used and beneficial impacts are experienced across a wider range of people. Capital and operating costs of the facility may also be reduced as these are shared between a larger number of organizations or individuals. This concept can be applied to health facilities in a range of different ways. For instance, sharing arrangements with a local sport club or fitness center can be used to enable a health facility to use swimming pools and other facilities for rehabilitation without having the ongoing costs and management of this facility.

#Have shared use, and possibly development, of facilities been explored with local organizations?
#Have appropriate design considerations been put in place to ensure effective shared use of facilities?
#Have appropriate management considerations been put in place to ensure effective shared use of facilities?

===Social spaces===
Social spaces, such as canteens, cafes and common rooms can play an important role in the life of organization. They not only provide a respite from work environments they also provide a space for relaxed social interaction. This interaction and the relationships and communication networks created can may a significant impact in improving organizational effectiveness and responsiveness. In health care facilities this is a valuable resource which helps to motivate individuals and build strong teams that are able to provide effective and responsive health care.

#Have an appropriate number and type of social spaces been provided within the health facility?
#Will these facilities support easy social interaction within and between health teams, as well as cross health facility staff structures?

===Stakeholder involvement===
Involving people in decisions on issues will have an impact on them is a useful way of helping ensure that there is support for an initiative or a process. Structured involvement of stakeholder helps to ensure a shared understanding can be developed, joint decisions made and there is efficient and effective implementation. For instance, within a health facility, effective involvement of key stakeholders can help goals such as improved energy efficiency through ensuring that managers, building technical staff and health services staff understand the goal, the means that this will be achieved and can see their role in supporting this.

#Has there been appropriate stakeholder involvement in the design of health facilities?
#Has there been appropriate stakeholder involvement in the management of health facilities?

==REFERENCES==

#[http://www.cidb.org.za/publications/Documents/Greenhouse%20Gas%20Emission%20Baselines%20and%20%20Reduction%20Potentials%20from%20Buildings%20in%20South%20Africa.pdf CIDB, 2009. South African Report on Greenhouse Gas Emission Reduction, Potentials from Facilities, A Discussion Document. Construction Industry Development Board. Page 22].
#. DEAT, 1995. Urban Open Space: Guidelines for effective management. Discussion document based on Agenda 21 and the RDP
#[https://www.environment.gov.za/sites/default/files/gazetted_notices/nema_guidelines_g33333gen654_0.pdf DEAT, 1998. National Environmental Management Act. Department of Environment and Tourism, Pretoria. Chapter 1.]
#[https://resource.capetown.gov.za/documentcentre/Documents/City%20research%20reports%20and%20review/State_of_Environment_Report_2009_2010-08.pdf DEAT 2009, State of the Environment Report] Accessible from http://soer.deat.gov.za/themes.aspx?m=387
#[https://www.environment.gov.za/sites/default/files/legislations/national_climatechange_response_whitepaper_0.pdf DEAT, 2009a, The National Climate Change Response Policy. Department of Environment and Tourism, Pretoria. Page 8.]
#[https://www.environment.gov.za/sites/default/files/legislations/national_climatechange_response_whitepaper_0.pdf DEAT, 2009b, The National Climate Change Response Policy. Department of Environment and Tourism, Pretoria. Page 14]
#[https://www.environment.gov.za/sites/default/files/legislations/national_climatechange_response_whitepaper_0.pdf DEAT, 2009c, The National Climate Change Response Policy. Policy Department of Environment and Tourism, Pretoria. Page 20].
#[https://www.ekurhuleni.gov.za/council/reports/environmental-reports/469-environmental-managment-framework-2008/file.html EMM and GDACE, 2007. Environmental Management Framework for Ekurhuleni. Ekurhuleni Metropolitan Municipality and Gauteng Department of Agriculture, Conservation and the Environment]
#[https://www.researchgate.net/publication/260034209_General_conclusions_on_development_of_plausible_climate_change_scenarios_for_southern_Africa Hewitson, B. Engelbrecht, F Tadross, M. and Jack, C., 2005. General conclusions on development of plausible climate change scenarios for southern Africa, in: R. E. Schulze (ed.), Climate Change and Water Resources in Southern Africa: Studies on Scenarios, Impacts, Vulnerabilities and Adaptation, Water Research Commission, WRC Report 1430/1/05, Pretoria, South Africa.]
#[https://www.ipcc.ch/site/assets/uploads/2018/02/ar4_syr_full_report.pdf IPCC, 2007. Climate Change 2007, Synthesis Report. Inter Governmental Panel on Climate Change. 2007.Page 7]
#[https://www.cityenergy.org.za/uploads/resource_82.pdf SEA 2006, . Sustainable Energy Africa. Cape Town.]
#[http://www.woodybpower.biz/Sans%20204.pdf South African Bureau of Standards. 2007. SANS 204 Energy Efficiency in Facilities]
#[[WWF 2004. Living Planet Report 2006.World Wildlife Fund]].

==APPENDIX A: SUSTAINABILITY INTEGRATION PLANS==
 
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[[Category:Crosscutting Issues]]

Sustainability

2021-05-04T12:49:03Z

Tmojanaga: /* REFERENCES */

==INTRODUCTION==

==Purpose==
This document has been developed for the Department of Health to ensure that sustainable development is integrated into to planning and design of health facilities. The document defines sustainable development and outlines the implications of this for the built environment. It provides objectives and criteria that can be used in the development health facilities in South Africa.

==Background==
The Department of Health wish to support sustainable development in South Africa and ensure that there is an appropriate balance between economic development, social integration and protection of the environment.
Global Warming and South African legislation and policy now make it imperative that built environment projects address sustainability. However, there is limited South African guidance on how sustainable development can be integrated with built environment projects. There is also the perception that addressing sustainability in facilities will be expensive and complicated.
This document provides guidance and checklists that can be used to support the integration of sustainability into health facilities. It shows that by addressing sustainability early in projects, additional costs can be minimised and innovative, high-performance solutions that benefit society, the economy and the environment can be achieved. It also shows that achieving more sustainable facilities need not be complex but can be based on robust, sensible and simple measures.

==How to use this document==

This document provides a framework that can be used to inform the development of health facilities. It can be used in the following ways:

*'''Awareness''': This document can be used to increase awareness about sustainable development and the need to address this in built environment projects. This will lead to more rigorous debate on development options and support more innovative and sustainable solutions.

*'''Setting sustainable development targets''': This framework can be used by a development team to set explicit and challenging sustainable development targets for projects. This is done by setting quantified targets against criteria in the document and putting in place systems to ensure that these are achieved.

*'''Self-assessments''': This framework can also be used for self-assessment and to ascertain the performance of development proposals. To carry this out refer to the Facility Recommended Compliance sheet and Compliance Checklist at the end of the document. This enables different health facility development proposals to be evaluated in terms of recommended compliance. Assessment using the criteria can also inform the design process by being used to evaluate different development options. This enables optimal solutions to be developed in an iterative and efficient way.

*'''Coordinated development''': Some criteria in the document may appear not to be in the remit of, or possible in, a single development. These criteria however can be achieved through partnerships and local collaboration. This framework can be used bring together the key role players in order to develop integrated plans that enable key sustainable development objectives to be achieved.

==Structure of the guideline==
The document has the following structure:

*'''Implementing Sustainable Development''': This section provides a description of sustainable development and translates this into specific sustainable development objectives for the built environment.

*'''Built Environment Sustainable Development Objectives''': In this section more detailed guidance and checklists are provided for each of sustainable development objectives listed in the section above.

*'''Sustainability Integration Plans''': This provides guidance on plans and a structure that can be used to integrated sustainability in design and operational processes.

==IMPLEMENTING SUSTAINABLE DEVELOPMENT==

===Introduction===
South Africa faces a range of social, economic and environmental challenges. HIV/AIDs has resulted in a life expectancy dropping from 67 years in 1998 years to around 47 years currently. Unemployment is estimated to be 27% and climate change is likely to lead to increasing water stress, reduced food security and loss of species and ecosystems (DEAT 2009).
Sustainable development, which aims to achieve social and economic improvements while reducing negative environmental impacts, can be used to address these challenges. Sustainable development however can be difficult to achieve. This is because a holistic and integrated approach is required and the development sector and in particular, the construction industry, operates in a highly fragmented way. In addition, the concept of sustainable development is still new and has not been adequately translated into practical actions that can be readily implemented.
This section defines sustainable development and translates this into key built environment objectives. It also describes the role of the built environment in creating environmental and other problems and shows how integrating sustainable development considerations into construction and the built environment can make a substantial contribution to improving the social, economic and environmental performance of the built environment.

===The environmental context===
Increasing carbon emissions from human activities and a reduction in the ability of the natural environment to absorb carbon dioxide is leading to an accumulation of greenhouse gases in the upper atmosphere. These gases trap more heat in the upper atmosphere leading to global warming and temperatures are predicted to increase by 2 - 6°C OC by the end of the century (IPCC, 2007). Estimates carried out for the City of Joburg indicate that temperatures in the next 50 years may increase between 2 and 3.5°C (Hewitson, Engelbrecht, Tadross, Jack, 2005).

Within Africa, South Africa produces the highest CO2 emissions and has one of the highest CO2 emissions per GDP in the world. In 2002, carbon emissions per capita in South Africa were 8.4tonnes/capita - higher than Western European averages of 7.9tonnes/capita (SEA 2006).
Global warming is likely to impact Africa particularly negatively. The National Climate Change Response Policy Developed by the Department of Environment and Tourism outlines the following impacts (DEAT 2009a):

*Agricultural production and food security in many African countries are likely to be severely compromised by climate change and variability. Projected yields in some countries may be reduced by as much as 50% in some countries by 2020 and as much as 100% by 2100. Small scale farmers will be most severely affected.

*Existing water stresses will be aggravated. About 25% o Africa’s population (about 200million people) currently experience high water stress. This is projected to increase to between 75-250 million by 2020 and 350-600 million by 2050.

*Changes in ecosystems are already being detected and the proportion of arid and semi-arid lands in Africa is likely to increase by 5-8% by 2080. It is projected that between 25 and 40% of mammal species in national parks in sub-Saharan Africa will become endangered.

*Projected sea-level rises will have implications for human health and the physical vulnerability of coastal cities. The cost of adaptation to sea level rise could amount to 5-10% of gross domestic product.

*Human health will be negatively affected by climate change and vulnerability and incidences of Malaria, Dengue fever, Meningitis and Cholera may increase.

===The contribution of the built environment===
Construction and the built environment make a substantial contribution to global warming and play a significant role most economies. Environmental, social and economic impacts attributed to the built environment at a global scale are outlined below.

*Consumes 40% of energy use,

*Consumes 17% of fresh water use,

*Consumes 25% of wood harvested,

*Consumes 40% of material use,
*Employs 10% of the world’s work force,

*Construction is the largest employer of micro-firms (less than 10 people),

*Facilities are typically located on the most productive land (Estimated to be 250 million hectares world wide, mostly on primary agricultural land).

In South Africa the built environment is directly responsible, through electricity consumption, for over 23% of South Africa’s carbon emissions (see table below). Vehicle-based infrastructure and transport planning has resulted in transport contributing to 16% of South Africa’s CO2 emissions and an additional 18mtCO2 per year, or about 4% of South Africa’s CO2 emissions, come from the manufacture of building materials (CIDB 2009).

Sector C02 Emissions

Commercial 10%

Residential 13%

Transport 16%

Industry 40%

Mining 11%

Other 10%

Total 100%

''Figure 1: South African carbon emissions per sector''

===Defining sustainability===
Recent work by the World Wildlife Fund contributes substantially to defining sustainable development by providing quantified minimum criteria for sustainability. In the 2006 Living Planet Report, sustainability is defined as achieving an Ecological Footprint (EF) of less than 1.8 global hectares per person and an Human Development Index (HDI) value of above 0.8 (WWF 2006).

===Ecological Footprint===
An Ecological Footprint is an estimate of the amount of biologically productive land and sea required to provide the resources a human population consumes and absorb the corresponding waste. These estimates are based on the consumption of resources and production of waste and emissions in the following areas:

*Food, measured in type and amount of food consumed,

*Shelter, measured in size, utilization and energy consumption,

*Mobility, measured in type of transport used and distances travelled,

*Goods, measured in type and quantity consumed.

*Services, measured in type and quantity consumed The area of biologically productive land and sea for each of these areas is calculated in global hectares (gha) and then added together to provide an overall ecological footprint. This measure is particularly useful as it enables the impact of infrastructure and lifestyles to be measured in relation to the earth’s carrying capacity of 1.8 global hectares (gha) per person.

===The Human Development Index===
The Human Development Index was developed as an alternative to economic progress indicators and aimed to provide a broader measure that defined human development as a process of enlarging people’s choices and enhancing human capabilities (United Nations Development Programme 2007). The measure is based on:

*A long healthy life, measured by life expectancy at birth,

*Knowledge, measured by the adult literacy rate and combined primary, secondary, and tertiary gross enrolment ratio,

*A decent standard of living, as measure by the GDP per capita in purchasing power parity (PPP) in terms of US dollars.

===South African EF and HDI figures===
The figures below show that South Africa has an ecological footprint of 2.1, above the maximum required of 1.8 gha and a human development index measure of 0.66, below the minimum of 0.8 required for sustainability.

Measure South Africa Sustainability Target
Ecological Footprint (gha) 2.1 1.8
Human Development Index 0.658 0.8
{| class="wikitable"
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!Measure
!South Africa
!Sustainability Target
|-
|Ecological Footprint (gha)
|2.1
|1.8
|-
|Human Development Index
|0.658
|0.8
|}

For South Africa to move towards sustainability there must therefore be an improvement in both the Ecological Footprint and Human Development Index performance. The built environment has a key role in supporting this improvement.

===The legislative and policy context===
South Africa has a range of legislation and policy that aims to protect the environment and support sustainable development. Key legislation supporting sustainable development includes the South African Constitution and the National Environmental Management. These are discussed briefly below.

===South African Constitution===
The South African Constitution contains a Bill of Rights that enshrines the rights of all people in South African and affirms the democratic values of human dignity, equality and freedom. The Bill has sections covering equality, human dignity, privacy, freedom of religious belief and opinion, environment, property, housing, healthcare, food, water and social security, children, education, language and culture. Through a section on equality, the Bill requires that all people have full and equal enjoyment of these rights and freedoms:

''Everyone is equal before the law and has the right to equal protection and benefit of the law.''

Equality includes the full and equal enjoyment of all rights and freedoms. To promote the achievement of equality, legislative and other measures designed to protect or advance persons or categories of persons, disadvantaged by unfair discrimination, may be taken.
Environmental rights in the Bill of Rights include the right to an environment that supports health and wellbeing. It also requires legislation to be developed to ensure that the environment is protected and that development that does occur is both sustainable, and justifiable:

===Environment===
Everyone has the right

a). to an environment that is not harmful to their health or well-being; and

b). to have the environment protected, for the benefit of present and future generations, through reasonable legislative and other measures that ¬

#prevent pollution and ecological degradation;
#promote conservation; and
#secure ecologically sustainable development and use of natural resources while promoting justifiable economic and social development.

Sustainable development and the protection of the environment is, therefore, a constitutional obligation and there is a requirement for ‘reasonable legislative and other measures’ to be put in place to ensure that this achieved. '''This document represents a measure taken by the Department of Health to achieve sustainable development.'''

===Carbon emission mitigation strategies===
South Africa is a signatory to both the United Nations Framework Convention on Climate Change (UNFCC) and the Kyoto Protocol. In order to address UNFCC commitments, the Long Term Mitigation Scenarios (LTMS) process was initiated in 2006 and completed in 2008. This formulated strategies to ensure that South Africa would reduce carbon emissions. Many of the mitigation strategies identified have implications on the built environment and these are outlined below (DEAT 2009b):

*Limits on less efficient vehicles

*Passenger modal shift
*Solar water heater subsidy

*Commercial efficiency
*Residential efficiency

*Renewables with learning

*Waste management

*Land use: afforestation

*Escalating CO2 tax

Following the LTMS process, key policy approaches were agreed on by the South African cabinet. These strengthen current energy efficiency and demand-side management initiatives such as environmental fiscal reform and carbon taxation which will penalize energy inefficient technology and provide for additional tax allowances of up to 15% for energy-efficient equipment.
The LTMS process however also showed that although significant emission reductions could be achieved through technology-based actions, these were not sufficient for the scale of change required and that adaptations in social behaviour would be required. (DEAT 2009c).The LTMS, therefore, proposed a number of people and building orientated measures that offered low-cost large scale mitigation impacts including:

*Social adaptation and changes in human habitation, urban planning and the built environmental

*Studies on the distance between work, home and other life functions

*Modal shifts to public transport and moves away from individual car owners towards the operation of shared vehicles

*Food production and consumption, as well as the localization of these activities

==Built environment sustainable development objectives==
The environmental context, legislation and potential future measures to reduce carbon measures make it clear that the built environment must change to support sustainable development. It also makes it clear that many of the conventional practices in the planning, design, construction and management of building must be substituted with improved more sustainable approaches.
In order to develop practical measures that can be integrated into the built environment, it is useful to set out built environment or development objectives that, together, would support sustainable development. These objectives are outlined below and form the starting point for the next sections of this document where more detailed criteria are provided.

===Environmental objectives===

*Energy: The building is energy efficient and uses renewable energy

*Water: The building minimises the consumption of mains potable water.

*Waste: The building minimizes emissions and waste directed to landfill

*Materials: Construction impacts of building are minimized
*Biodiversity: The building supports biodiversity

===Economic objectives===

*Transport: The building supports energy efficient transportation
*Resource Use: The building makes efficient use of resources
*Management: The building is managed to support sustainability
*Local Economy: The building supports the local economy
*Products and Services: The building supports use of more sustainable products and services

===Social objectives===

*Access: The building supports access to facilities

*Health: The building supports a healthy and productive environment

*Education: The building supports education
*Inclusion: The building is inclusive of diversity in population

*Social Cohesion: The building supports social cohesion

===Integrating sustainable development objectives into health facilities===
Integrating sustainable development objectives requires structured processes. These are described below in terms of design and operational processes.

===Design processes===
Addressing sustainability in designs for new health facilities can be achieved through the following steps:

'''Target setting:''' Challenging sustainability targets should be set for the building and agreed with all of the key stakeholders of the project including the design team, the facilities manager and the funder or owner of the building. Targets should take into account government policy and strategies as well as local and international best practice.

2. '''Design principles:''' Strategies and design principles required to achieve these sustainability objectives should be understood and established from the outset. For instance, energy targets may require passive environmental control strategies to be well understood and established from the outset. These strategies and their implications can be understood through analysis of best practice examples and precedents.

3. '''Integrated design:''' Once targets and design principles have been established, an integrated design process should be used to ensure that all aspects of the building work together to achieve the required performance. This requires the different disciplines to work closely together.

4. '''Testing:''' Throughout the design process, checks should be carried out to ensure that targets set will be achieved. This can be done through calculations, modelling and analysis which assesses performance against targets set. Where aspects of the design are found not to meet targets a re-evaluation of the design should be carried out and in an iterative and integrated way, improved, to ensure that performance achieves, or surpasses, targets set.

5. '''Detailed design and implementation:''' It is important to ensure that the principles set out in 2 above, are carried out in to detail otherwise this may affect operational performance. This includes, for instance, details such as appropriate locations for switches, labels and instructions.

6. '''Handover:''' On completion, effective processes should be followed to ensure that design intentions are carried through into building operation. This includes effective commissioning, handover and training processes which ensure that designers, subcontractors and suppliers transfer knowledge and skills to facilities managers required to ensure effective management of the building.

===Operational performance===
Addressing sustainability in existing or newly developed health facilities can be achieved through the following steps:

#'''Data''': Obtain operational performance data on your building for at least a full year. For energy, this can be obtained in the form of utility statements that indicate energy consumption in kWh.
#'''Benchmark''': The above data should be normalised so that it can be compared to benchmarks. This will indicate whether your facility is below or above benchmark performance. If performance is well over benchmark, further investigation should be carried out, as this indicates there is room for improvement.
#'''Walkthrough assessment''': A walkthrough energy assessment can be used to identify where obvious improvements can be made. Checklists are used as a basis for these assessment and they can be carried out by health facilities personnel with training or experience of the respective areas such as water and energy.
#'''Audit''': Where walkthrough assessments and benchmarking exercise indicate that a full audit is warranted this can be carried out. These audits provide detailed reports on interventions that can be carried out to improve sustainability performance in a facility.
#'''On-going operational performance''': A key component of improving sustainability operational performance, in combination with the steps above, is an on-going programme that improves performance. This includes detailed sustainability monitoring and reporting as well as day-to-day management processes required to optimise performance. Operational performance should be allocated to an individual who is required to report on this to senior management. Identified responsible persons should be provided with appropriate training, resources and incentives to achieve excellent energy performance.

==='''Sustainability integration plans'''===
The above processes can be supported through sustainability integration plans which present targets, strategies and monitoring process for each sustainability performance areas. The simplest form of this is illustrated in the table below and can be used for both design and operational processes.

Area Targets Strategy Monitoring
Sustainability performance area Sustainability targets and requirements Proposed strategy and processes Progress on achievement of targets
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==ENERGY==

===Objective===
The building is energy efficient and uses renewable energy

===Introduction===
Energy is used in health facilities to operate equipment, heat water, and to ensure that required minimum lighting, ventilation and thermal comfort standards are met. In most existing South African building it is estimated that savings of up to 30% of energy consumption can be achieved at no or low cost. These savings can be considerably higher in new facilities were passive strategies, energy efficient equipment and renewable energy systems can be used.

Ensuring that health facilities are more energy efficient use renewable energy has a wide range of benefits including:

*Reduced carbon emissions and therefore global warming impacts

*Reduced impact of mains power outages

*Reduced negative health impacts of pollution from coal-fired power stations

*Reduced operational costs

*Improved internal environment where passive strategies such as day lighting and natural ventilation lead to improved internal conditions relative to mechanical ventilation and artificial lighting.

===Energy consumption in health facilities===
Energy in South African health facilities is largely sourced from electricity, however gas and coal may also be used in larger hospitals and some rural clinics rely on local renewable energy systems such as photovoltaic panels and solar water heaters. The proportions of energy use in a conventional South African hospital and clinic are shown in the pie charts below:
{| class="wikitable"
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!
|-
|Proportions of energy consumption in a typical South African hospital
|Proportions of energy consumption in a typical South African clinic
|}

Data on energy consumption and demand in South African facilities is not readily available. However the following table provides a number of benchmarks 1
{| class="wikitable"
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!Energy benchmark type
!Typical
!Good practice
|-
|Clinics
|
|
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|Energy consumption (kWh/m2.a)
|1
|1
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|Maximum demand (VA/m2)
|1
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|Renewable energy (kWh/m2.a)
|0
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|Hospitals
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|
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|Energy consumption (kWh/m2.a)
|395 2
|1
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|Maximum demand (VA/m2)
|1
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|Renewable energy (kWh/m2.a)
|0
|
|}
 
===Design Criteria===
Highly energy efficient facilities are optimized and integrated solutions that respond closely to the local site, climate and required internal functions. It is therefore difficult to prescribe this in a set of specific design criteria; however a series of questions are outlined below which can be used to check that key energy considerations have been addressed.

===Design and operation===
Improving energy performance in health facilities requires plans, procedures and processes that ensure that sustainability is integrated effectively into design and operations of a health facility. This can be achieved through setting challenging targets and effective monitoring processes.

#Have challenging sustainability targets been set for energy?
#Have effective procedures been established to model and test performance throughout the design process to ensure that these targets are achieved?
#Have the effective monitoring and evaluation systems, including regular reporting to the client, been put in place to ensure targets are achieved?
#Have capacity and systems in the form of staffing, training, manuals, commissioning and monitoring processes been planned for and put in place to ensure that design targets are achieved in operation.

===Orientation===
Orienting facilities so that the long facades face North – South helps to reduce unwanted heat gains from low angle sunlight early in the morning and late in afternoon. Where there is no alternative but to have facades face East and West, appropriate solar shading should be provided to avoid glare and control solar heat gain.

1. Are the long facades of facilities orientated to face within 15 degrees of a North – South orientation?

2. Is glazing on West and East facades minimized?

===Building shape===
While building shape and form may generally be determined by the functions accommodated, building form can also be shaped to minimise energy consumption. Shaping built form to limit building depth (see below) ensures that interior spaces can be naturally ventilated and day lit. Built form can also direct prevailing breezes through the facilities, supporting cooling and ventilation. It can also be used to create comfortable external spaces.

#Does the form of the building respond to local climate and topography?
#Does the building shape support reduced energy consumption and help create comfortable internal and external spaces?

===Building depth===
Limiting building depth enables internal space to be day lit and naturally ventilated. This ensures that internal space may not need artificial lighting or mechanical ventilation for much of the day, reducing energy consumption.

#Are building depths less than 15m?

==='''Insulation'''===
Insulation, especially when combined with thermal mass can be used to maintain comfortable indoor conditions without significant use of mechanical equipment. Insulation can ensure that valuable heat gains from people, equipment and the sun can be retained in the building to support comfort during winter. It can also reduce unwanted heat gains from ambient conditions in summer.

#Do the building envelope U-values achieve or surpass minimum values outlined in SANS 204 (SABS 2008)?

==='''Solar shading and glazing'''===
Glazing is usually the most vulnerable area of a building envelope and high heat losses and gains can be experienced through this component. It is therefore important to design glazing and devices which enable light and heat flow to be controlled.

#Is the glazing to wall ratio compliant with SANS 204 (SABS 2008)?
#Is solar shading compliant with SANS 204 (SABS 2008)?
#Has glazing with appropriate U-values, visual transmittance and solar heat gain coefficients been selected?

===Opening areas===
Opening areas within the building envelope such as doors and windows can be used to naturally ventilate the building. In general, it is advisable to provide for openings even in facilities that are mechanically ventilated and cooled as this enables them to be occupied and used in the event of a power cut.

#Are opening areas located to support effective natural ventilation?
#Is the area of openings provided compliant with SANS 10400 XA:2011?

Air tightness

Uncontrolled infiltration and airflow through the building envelope can affect comfort and increase heating and cooling loads in the building.

#Has careful detailing and specification been used to minimise infiltration in the building.
#Has a plan for rigorous construction supervision been put in place to ensure that building envelopes are air tight?

===Mechanical systems===
As far as possible mechanical cooling, heating and ventilation should be avoided. If this is not possible, a mixed mode operation should be selected. Mixed mode operation use mechanical system when ambient and internal conditions require this, but otherwise rely on passive systems to maintain thermal comfort and meet ventilation rate requirements. In particular circumstances mechanical cooling, heating and ventilation may be required for much of the year.

#Can the building or most of the spaces be passively cooled, heated and ventilated without the requirement for mechanical systems?
#If the application of passive systems will not achieve an acceptable number of annual comfort hours, can complementary mechanical systems be introduced to meet the comfort and ventilation requirements?
#Where zones exist within a facility that are not tolerant of passive ventilation and comfort systems, can a zoned mixed mode ventilation strategy be adopted?
#Where mechanical systems have been used has a rigorous exercise been undertaken to identify the most appropriate and energy efficient system?
#Where mechanical systems have been used do these include features that help reduce energy consumption such as:

a. An economy cycle

b. Controls that enable easy systems adjustments in order to benefit for seasonal and occupancy changes.

===Equipment===
As equipment used in building can consume large amounts of energy, the energy efficiency of equipment and energy ratings should be a key consideration. In addition, controls that ensure equipment is switched off when not in use should be specified.

#Is energy efficiency a key consideration in the selection of equipment?
#Is benchmarking energy consumption or energy rating used to support the selection of equipment?
#Are the controls provided for equipment easy to use and do they ensure that equipment is off when not required?

===Internal lighting===
Ensuring adequate lighting levels may be a key consideration in many spaces within health building. This should however be achieved in the most energy efficient way. Lighting is rapidly becoming more energy efficient and there are increasingly sophisticated controls.

#Is energy efficiency a key consideration in the selection of lighting?
#Has a rigorous evaluation process, including lighting power density calculations, been undertaken to ensure that the selected lighting system is highly energy efficient?
#Have appropriately sized lighting zones (ie under 100m2) been designed to avoid lighting being on where it is not required.
#Are lighting switching arrangements easy to use and encourage users to switch off lighting when not required?
#Are motion sensors used to switch lighting off in areas such as store rooms and meeting rooms when these are not used?
#Are daylight sensors used to switch lighting off in areas where these is adequate daylight? Areas with good daylight are usually found within a zone of about 6 m from external windows.
#Can light harvesting techniques and systems be incorporated in the design solution?

===External lighting===
Concerns about security often result in highly lit external areas. While security and building access requirements must be met, external lighting should be designed to be as energy efficient as possible.

#Are only areas that specifically require external lighting included?
#Has external lighting been provided as close to the area that requires lighting as possible and directed in order to avoid losses and light pollution?
#Are photo sensors, motion sensors or timers used to ensure that lighting is only on when required?

===BMS system===
Building Management Systems (BMS) should be used in complex building with complex equipment and systems. A BMS enables different systems to integrated and controlled and can support energy efficiency

#Has a BMS been used to coordinate and integrate systems, where complex systems are used in a large building?
#Is the BMS easy to use and understand?
#Is there local training and support for the BMS>
#Is the BMS system developed to open protocols and standards?
#Does the BMS include features that support energy efficiency such as:

a. Easy access to equipment schedules so that these can easily be changed to suite occupancy patterns.

b. Reminders to ensure that BMS operator tune building systems for greatest energy efficiency. For instance the system may provide a reminder to change air conditioning set points to match seasonal changes.

c. Reporting on water and energy sub metering and related equipment schedules.

===Sub metering===
An appropriate sub-metering system enables effective energy management. A facilities manager can see how much energy is used in different areas or uses in the facility. Sub-meters also show when and how energy is used through for instance energy profiles which show energy consumption and demand over time.

#Has an energy sub metering design been developed that will monitor all of the main energy uses in the facility?
#Is energy management data provided in formats and reports that can be easily understood and analyzed to support improved energy management?
#Does the system provide energy management report that can be used by both facilities managers and senior managers to improve energy efficiency in the facility?

===Renewable energy===
Increasingly renewable energy is becoming a competitive alterative to ESKOM supplied power. It also has the advantage that it increases the energy autonomy and independence of facilities, allowing these to operate even when there are mains power cuts.

#Are solar water heaters used to heat water in the facility?
#In areas with high quality, reliable sunlight, are photovoltaic systems used to reduce the reliance on ESKOM power?
#In areas with high quality, reliable wind, are wind turbines used to supplement to reduce the reliance on ESKOM power?

==WATER==

===Objective===
The building minimises the consumption of mains potable water.

===Introduction===
Water is used in health facilities for cleaning equipment, utensils and facilities, laundry, irrigation, food preparation and for drinking. In most existing South African health facility it is possible to reduce mains potable water consumption at no or low cost. These savings can be considerably higher in new facilities where water efficient technologies, grey water and rainwater systems can be used.

Ensuring that health facilities are more water efficient has a wide range of benefits including:

*Reduced water consumption and associated negative environmental impacts
*Reduced impact of mains water shortages or outages
*Reduced operational costs

===Water consumption in health facilities===
Water in South African health facilities is largely sourced from municipal potable water supply, however in some areas water may come from a rain water tanks or a borehole. The proportions of water use in a conventional South African hospital and clinic are shown in the pie charts below:
{| class="wikitable"
|+
!
!
|-
|Proportions of water consumption in a typical South African hospital
|Proportions of water consumption in a typical South African clinic
|}



Data on energy consumption and demand in South African facilities is not readily available. However the following table provides a number of benchmarks 1
{| class="wikitable"
|+
!Water benchmark type
!Typical
!Good practice
|-
|Clinics
|
|
|-
|Water consumption (kl/m2.a)
|1
|1
|-
|Hospitals
|
|
|-
|Water consumption (kl/m2.a)
|70 2
|1
|}
 

===Criteria===
The consumption of mains potable water in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective performance requirements within the health facility; however a series of questions can be used to check that key water considerations have been addressed. These are outlined below.

===Wash Hand Basin Taps===
Controlling and reducing water flows in wash hand basin taps can be used to reduce water consumption.

#Are wash-hand basin tap flow rates should not exceed 6L/minutes?
#Are passive infra-red (PIRs) or push-button controls used to limit the duration of flows?
#Has legionella control been considered when designing for low flow and systems and where existing system are made redundant?

===Toilets===
Reducing flush rates in water-borne sanitation can be used to reduce water consumption.

#Have WC flush rates been specified that do not exceed 6L/flush?
#Have dual flush controls can be used to ensure that reduced flush rates can be used when full flushes are not required?

===Showerheads===
Controlling and reducing water flows in showers can be used to reduce water consumption. The following measures can be considered:

#Have shower head flow rates been specified to not exceed 10L/minute?
#Are push-button type controls used to limit the duration of flows?
#Has legionella control been considered when designing for low flow and systems and where existing system are made redundant?

===Irrigation===
Minimizing irrigation water requirements can be used to reduce water consumption. The following measures can be considered:

#Are locally indigenous species (species found in the local area) used to minimise irrigation requirements?
#If irrigation is required, are highly efficient water delivery systems, such as a drip irrigation linked to soil moisture probes, used to minimise irrigation requirements.
#Has grey water been used to avoid the use of potable water for irrigation?

===Grey water systems===
Grey water systems reduce mains potable water consumption by reusing lower quality water within the facility. Examples of this are where waste water from showers and wash hand basins is captured and reused to flush toilets. Other sources of grey water include waste water from laundries and HVAC systems. Grey water systems however are potentially hazardous to human health, particularly in health facility environments. In particular, grey water which is left to stand for over 36 hours or is contaminated by food or similar waste is considered as blackwater and requires the same treatment as sewage. Therefore, grey water systems should only be designed, implemented and operated by appropriately competent people. Potential grey water applications in health facility environments are described below:

*Wash hand basin and shower waste water: Waste water from wash hand basins and showers can be directed to a grey water system and then used to flush toilets or for landscape irrigation.
*Vehicle wash: Waste water from vehicle waste can be reused to wash vehicles for up to 3 or 4 times. After this it can be disposed of or used for irrigation.
*HVAC plant: It may be possible to use waste water from HVAC systems for irrigation or to flush toilets. To ascertain if this is possible investigations should be carried out with the HVAC manufacturer and grey water specialists.

The following considerations in relation to grey water systems should be made:

*Have significant sources of grey water from, for instance, showers and wash-hand basins, been captured in a grey water system?
*Are grey water usage points appropriately labelled to prevent unsafe consumption.
*Will this grey water be used for irrigation or to flush toilets in order to significantly reduce portable water consumption?
*Is the proposed grey water system easy and cost effective to maintain?
*Have as many of the potential health hazards associated with the system been eliminated?

===Rain water systems===
Rain water systems store water captured from roofs or hard landscape surfaces. This water is then available for irrigation, to flush toilets or for cleaning. In large facilities very substantial amounts of water can be captured and used to reduce mains potable water consumption. A number of different types of systems are described below:

*Roof rainwater harvesting: Rainwater from roofs is directed to tanks and stores. Usually a proportion of initial run-off is directed to waste as it may have picked up dust and other debris. This system is the most common and generally has the lowest cost as rainwater tanks can be installed above ground surface.
*Hard surface rain water: This system captures storm water run-off from hard surfaces such as game pitches, paths and car parking. This type of system generally requires some form of filtration to remove debris, and in the case of car parking, oil wastes. Tanks are usually sub-surface.
*Landscape surface run-off capture: Surface run-off from soft landscaping can be captured and reused. This is sometimes used as part of an onsite storm water retention strategy. The disadvantage of this system is that the resulting water quality can be poor as debris and silt may be picked up. The filtration and maintenance requirements are therefore more stringent.

The following considerations in relation to rain water systems should be made:

#Have significant sources of rain water from roof and hard surfaces been captured in a rainwater harvesting system?
#Will this rain water be used in functions such as irrigation or to flush toilets in order to significantly reduce portable water consumption?
#Is the proposed rainwater harvesting system easy and cost effective to maintain? Have as many of the potential health hazards associated with the system been eliminated?

==WASTE==

===Objective===
The building minimizes waste directed to landfills.

===Introduction===
Waste in South African health facilities is largely directed to landfill sites. Not only does this use up valuable land, but can also lead to air, soil and water pollution if not waste is not disposed of correctly. In addition, this waste also consists of valuable resources that could be easily reused and recycled. Recycling and reusing materials not only reduces energy and resource consumption but can also create jobs and additional revenue streams.

Ensuring that health facilities minimise waste and reuse and recycle waste products are as follows:

#Reduced loss of land area to landfill
#Reduced energy and resource consumption
#Potential to create jobs and small enterprises

===Waste production in health facilities===
Waste in South African health facilities is largely directed to landfill sites. However in some area waste may be disposed of by local recyclers. The proportions of waste generated use in a conventional South African hospital and clinic are shown in the pie charts below:
{| class="wikitable"
|+
!
!
|-
|Proportions of waste in a typical South African hospital
|Proportions of waste in a typical South African clinic
|}

Data on waste in South African facilities is not readily available. However the following table provides a number of benchmarks 1
{| class="wikitable"
|+
!Waste benchmark type
!Typical
!Good practice
|-
|Clinics
|
|
|-
|Waste production (kg/m2.a)
|1
|1
|-
|Proportion of waste recycled or reused
|10%
|
|-
|Hospitals
|
|
|-
|Waste production (kg/m2.a)
|1
|1
|-
|Proportion of waste recycled or reused
|10%
|
|}

===Criteria===
Waste in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that key waste considerations have been addressed. These are outlined below.

===Provision for recycling===
Recycling can be encouraged by developing systems that make this easy. This includes providing easy-to-use receptacles for different types of waste and providing space in the right locations so that waste can be stockpiled into worthwhile quantities for a recycler to collect.

#Are there appropriate waste receptacles at the waste source to enable waste to be disposed of easily?
#Are there adequate number and type of waste receptacles at source to ensure that the value of waste is not reduced as a result of wastage or mixing of waste? For instance, clean waste paper can be spoilt if mixed with food waste.
#Has adequate storage space been provided in an appropriate location for the different recycling waste streams so that this waste can be stockpiled and easily accessed recycling contractors?

===Engagement with local recyclers===
Engaging with local recyclers earlier in the development of a new or refurbished facility can be used to understand the recycling process and the key requirements to make this effective.

#Have all the potential waste streams been identified? These include paper, cardboard, tin, glass, plastic, timber, electrical appliances etc?
#Have appropriate associations and local recyclers related to each of these waste streams been engaged with a view to ensuring that appropriate provision and systems are put in place to maximised recycling.

===Engagement with suppliers===
Engaging with suppliers can be used to reduce waste and transportation impacts. Waste and transportation impacts can be reduced through reduced use of packaging, use of reusable containers and optimized logistic supply chains.

#Have all suppliers of substantial goods and services to the health facilities been identified? Have these been engaged in relation to transportation and packaging with a view to minimising impacts in these areas?
#Has provision been made to reduce packaging waste and transport impacts through aspects such as increased space allowances for releasable containers and storage of products?

===Construction waste===
Construction is a major source of landfill waste. Waste from construction however can usually be easily reduced through explicit planning and monitoring processes.

#Has was construction waste minimization and recycling been included as specific requirement within tender and contract documents?
#Has the contractor been asked to develop a construction waste management plan in order to minimise waste? Does this plan include specific construction waste management targets ie 50% of all waste on site will be recycled? Have the parties responsible for implementing the plan been identified clearly and have they been given the mandate and resources to implement the plan? Has an appropriate monitoring and evaluation systems been put in place to ensure targets are achieved?

==MATERIALS==

===Objective===
Construction impacts of building are minimized

===Introduction===
Materials used in new facilities and the refurbishment of facilities can have significant impacts. Materials may be mined, processed, manufactured and transported before being incorporated in facilities. The extent and nature of the impacts of these stages varies widely depending on the material. The selection of materials and products to be used in facilities therefore is important in reducing negative environmental impacts.

Careful selection of construction materials used in health facilities has the following benefits:

*Reduced land and mining impacts
*Reduced environmental and health impacts from manufacturing processes
*Reduced transportation impacts
*Reduced material use
*Increased use of local sustainable materials

===Material use in health facilities===
Materials are used to construct South African health facilities and largely found in the building structure and envelope. More specialist materials and products such as refrigerants are found in equipment and systems within the building. The source and processes associated with construction materials and products have a wide range of impacts. It is therefore important to understand and confirm these with respective suppliers in order to select and specify materials and components with the least negative impacts.

===Criteria===
Material and component selection in health facilities can be addressed developing criteria list, communicating this to suppliers, and using this as a basis for specification and design. The nature of these criteria will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that key material and component considerations have been addressed. These are outlined below.

===Building reuse===
Using existing facilities instead of building new avoids or reduces the requirements for construction materials and therefore the impacts associated with extracting, manufacturing and transporting these. In addition, existing facilities are usually part of the urban fabric and already serviced with electricity, water, roads and public transport. Increasing the intensity of use of this fabric increases its efficiency and avoids the requirement to replicate this elsewhere. Therefore, in most circumstances it is preferable to reuse and refurbish existing facilities rather than build new facilities.

#Can the existing facilities continue to be used? If necessary, can these be refurbished and expanded rather than building a new facility?
#Are there other existing facilities that can be used? Can these be readily adapted for health use rather than constructing new facilities?

===Contribution to Global Warming===
Construction materials can contribute to global warming through carbon emissions associated with large amounts of energy used in their extraction, processing and transportation. This is referred to as embodied energy. Other materials such as refrigerant can contribute directly to global warming if they are released or leak into the atmosphere. Using existing facilities instead of building new avoids or reduces the requirements for construction materials and therefore the impacts associated with extracting, manufacturing and transporting these. In addition, existing facilities are usually part of the urban fabric and already serviced with electricity, water, roads and public transport. Increasing the intensity of use of this fabric increases its efficiency and avoids the requirement to replicate this elsewhere. Therefore, in most circumstances it is preferable to reuse and refurbish existing facilities rather than build new facilities.

#Refrigerants: Where refrigerants are being used in HVAC systems, cold rooms or in fire suppressions sytems have refrigerants with the lowest Global Warming Potential (GWP) and Ozone Depleting Potential (ODP) impacts been selected?
#High embodied energy materials: As far as possible, have construction materials with low embodied energy such as timber been selected? Where it is not possible to use these type of materials and high embodied energy materials such as cement and aluminium have to be use have the quantities of these materials been minimised?

===Reused materials or materials with recycled content===
Construction materials that are reused or have recycled content have less energy associated with their manufacture than equivalent new materials. Where possible, it is therefore preferable to reuse materials that may have already been used in another building or to select materials with recycled content.

#Are there materials from another building that is being demolished that could be reused? Aspects that can be reused include structure steel elements, facades, demountable structures such as carports, and building components such as windows and doors. Crushed concrete from demolished structures can also be used as aggregate in new construction.
#Have materials with recycled content been specified in preference to materials without any recycled content? Can the supplier / manufacture confirm the reduced environmental impacts of their recycled content product relative to new products?

===Reduced material use===
The quantity of construction materials used in facilities can be reduced through avoiding material use, using materials more intelligently and using materials for more than one use.

#Avoided material use: Have materials been avoided where these are not required? For instance, can ceilings and plastering be avoided through better concrete finishes? Can improved floor finishes be used to avoid the requirement for carpets and tiling? Can the use of passive systems reduce the requirement for ducting and plant?
#Intelligent material use: Can quantities of materials be reduced through different designs and specifications? For instance, can structural strategies such as pre-tensioning concrete slabs and waffle slabs be used to reduce concrete requirements? Can material use and wastage be reduced through use of precast elements?
#Dual plus use: Can materials be used for more than one purpose? For instance, can photovoltaic panels be used as a roofing material as well as to generate material?

===Material source===
The quantity of construction materials used in facilities can be reduced through avoiding material use, using materials more intelligently and using materials for more than one use.

#Avoided material use: Have materials been avoided where these are not required? For instance, can ceilings and plastering be avoided through better concrete finishes? Can improved floor finishes be used to avoid the requirement for carpets and tiling? Can the use of passive systems reduce the requirement for ducting and plant?
#Intelligent material use: Can quantities of materials be reduced through different designs and specifications? For instance, can structural strategies such as pre-tensioning concrete slabs and waffle slabs be used to reduce concrete requirements? Can material use and wastage be reduced through use of precast elements?
#Dual plus use: Can materials be used for more than one purpose? For instance, can photovoltaic panels be used as a roofing material as well as to generate material?

===Sustainable sources===
Materials can be defined in terms of whether they are from sustainable or non-sustainable sources. Materials from sustainable sources include timber, cork, wool that are grown and therefore can be harvested on an on-going materials. Other materials such as plastics and metals are mined and therefore once these sources are depleted will not be available.

#Where possible, have materials from sustainable sources been specified? For example, have timber, and plant-based products been used in preference to materials that have to be mined and processed?
#Are materials from sustainable sources actually being grown and harvested on a sustainable on-going basis? For instance, has timber specified been certified by the Forest Stewardship Council (FSC) as being from a sustainable source? It is important to note that there are still timber products available, in particular hardwoods, that are harvested from tropical rainforests which are not being replanted and therefore are not considered sustainable sources.

===BIODIVERSITY===

===Objective===
The building supports biodiversity

===Introduction===
Biodiversity plays a very important role for man through providing ecosystem services. Ecosystem services include the production of food and water, the control of climate and disease, supporting nutrient cycles and crop pollination and spiritual and recreational benefits.

Ensuring that health facilities take into account biodiversity has a wide range of benefits including:

*Maintaining local ecosystem services
*Providing an natural amenity such as gardens which would could support recuperation.

===Biodiversity in health facilities===
Health facilities affect biodiversity through their location and in the way that site planning and landscaping is carried out. New facilities can minimise negative impacts on biodiversity by avoiding green field sites and building outside municipal boundaries. Biodiversity within health facility sites can be supported through considered site planning and landscaping strategies.

===Criteria===
Biodiversity in health facilities can be addressed in a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key biodiversity considerations have been addressed. These are outlined below.

===Site location===
Biodiversity is being lost at a rapid rate through urban sprawl. Preserving existing biodiversity can therefore be achieved by avoiding green field site and building only within urban boundaries.

#Has the health facility been planned for a brown field (already built-on) sites?
#Has the health facility been planned for a location within an urban boundary so that this does not take up land that supports agriculture and or biodiversity.

===Design for biodiversity===
Biodiversity can be supported through site layouts and landscaping that retains existing biodiversity and enhances this.

#Has planning of the health facility ensured that existing valuable biodiversity on site is preserved?
#Have valuable links and wildlife corridors between biodiversity on the health facility and adjacent sites been preserved?
#Has the landscaping strategy enhanced existing biodiversity? Does this include the introduction of appropriate loc

==TRANSPORT==

===Objective===
The building supports energy efficient transportation

===Introduction===
Ensuring that health facilities support energy efficient transportation has a wide range of benefits including:

*Reduced air pollution and noise from vehicles
*Health benefits from increased opportunities for exercise
*More affordable transport for health facility users
*Reduced space requirements as a result of reduced parking and road requirements.

===Transportation in health facilities===
Transportation is important in health facilities as large numbers of people and goods need access to these facilities everyday. This includes health facilities staff who commute and health facilities users. The right location and provision of facilities help ensure that the transport impacts associated with this access is minimized and potential health benefits such as exercise are supported.

===Criteria===
The transportation in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that transportation considerations have been addressed. These are outlined below.

===Access to public transport===
Locating health facilities near public transport facilities and enabling good access to these encourage people to use these in preference to personal vehicles. The use of public transport can be encouraged by ensuring that health facilities are located near well used public transport nodes and that there are good walking routes between these and key locations within the health facility.

#Is the health facilities located near good public transport nodes such as minibuses, buses, trains and bus rapid transport systems?
#Are there safe, direct and easy-to-use routes between public transport nodes and key locations within the health facility? (see also provision for walking criteria)

===Provision for walking===
Making provision that encourages walking helps to ensure that people walk to health facilities instead of using vehicles. Walking can be encouraged through safe, direct and easy-to-use routes.

#Are there safe direct pedestrian routes to and around the health facilities site from neighboring areas and public transport nodes? (see also criteria 4 for detail)
#Are there safe direct pedestrian routes from neighboring areas to key locations within the health facility such as the main reception? (see also criteria 4 for detail)
#Are there safe direct pedestrian routes within the health facilities between all locations within the health facility? (see also criteria 4 for detail)
#Does pedestrian provision include safe road crossings such as bridges, underpasses and zebra crossings? Are routes wide enough and have appropriate finishes and other required characteristics to enable them to be easily used by people with disabilities and by predicted pedestrian numbers? Are routes safe and benefit from visual supervision by surrounding facilities and other pedestrians? Have lighting and appropriate security safety mechanisms been put in place if routes will be used at night?

===Provision for cycling===
Making provision that encourages cycling helps to ensure that people cycle to health facilities instead of using motorized vehicles. Cycling can be encouraged by providing secure cycle storage, changing or showering facilities and safe, easy-to-use local routes.

#Are there safe direct cycle routes to and around the health facilities site from neighboring areas? (see also criteria 4 for detail)
#Are there safe direct cycle routes from neighboring areas to key locations within the health facility such as the main reception? (see also criteria 4 below for detail)
#Are there safe direct cycle routes within the health facilities between all locations within the health facility? (see also criteria 4 for detail)
#Does this cycle provision include designated, separate routes and safe road crossings and junctions? Are routes wide enough and have appropriate finishes and other required characteristics to enable them to be easily used by predicted numbers of cyclists? Are routes safe and benefit from visual supervision by surrounding facilities and other cyclists? Have lighting and appropriate security safety mechanisms been put in place if routes will be used at night?

==RESOURCE USE==

===Objective===
The building makes efficient use of resources

===Introduction===
There are limited resources in the form of land, finance and raw materials to construct and maintain facilities. It is therefore important to use these resourced carefully. Benefits associated with careful resource use include:

*Avoiding waste
*Ensuring effective and efficient use of resources
*Ensuring that resources are available for other uses where these are not required

===Resource use in health facilities===
Health facilities use financial resources to enable construction and maintenance. They also consume materials and energy in their construction. Finally health facilities use land. Careful use of these resources enables waste to be avoided and these resources to be available for other uses where this is required.

===Criteria===
Resource in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that key resource considerations have been addressed. These are outlined below.

===Site density===
Detailed long term strategic plans for health facilities should be developed that take into account future projections. These should ensure that expansion or changes that are envisaged can be accommodated. However care should be taken that unnecessarily large areas are allocated for health facilities to avoid land being unused.

#Has a long term strategic site plan been developed for the health facility that addresses changes that may occur in the future, such as expansion or contraction?
#Has the over allocation of space for health facility sites been avoided?

===Occupancy density===
Robust sustainable facilities accommodate change through flexible and adaptable allocation and configuration of space. While this is important over provision of space should be avoided as this space will need to be serviced and maintained even if it is not used. Health facilities should therefore be designed to support spatial efficiency and effective use.

#Is the overall space allowance in the health facility in line or below health facilities norms, for instance, in terms of gross area per bed?
#Are the proportions of spaces use in the health facility in line with good practice health facilities design? For instance is the space allocated for circulation, support and ancillary services as a proportion of the total area in line with best practice norms?

===Food production===
Food production in the form of orchards or vegetable gardens are a productive way of using land that leads to both environmental and health benefits. Where land is available in health facility sites and there is water and appropriate capacity, food production should be encouraged and produce made available to be consumed within the health facility or by local communities.

#Has available land within the health facility site been developed for local food production?
#Has appropriate provision in the form of irrigation, fencing, organizational and capacity requirements been made to ensure that food production will be effective and sustained?

==MANAGEMENT==

===Objective===
The building is managed to support sustainability

===Introduction===
Facilities can be designed to support effective management. Systems can also be developed to ensure that facilities are effectively and efficiently used and maintained. In health facilities this is particularly important because of the stringent environmental requirements for health care and the high operating costs of the facility.

Ensuring that health facilities are effectively managed has a wide range of benefits including:

*Ensuring that operating costs are controlled and reduced
*Minimising disruption to health care as result of maintained and repairs
*Ensuring that maintenance is planned for and effective carried out

===Building management in health facilities===
Building management aims to ensure that health facilities are effectively operated and maintained in order to support healthcare services that they accommodate. Personnel with appropriate capacity, mandate and resources should be allocated to this function.

===Criteria===
Building management in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that building management considerations have been addressed. These are outlined below.

===Energy and water sub metering===
Energy and water sub metering enables the manager of a health facility to manage the consumption of energy and water and reduce costs associated with these services.

#Has energy sub metering been installed which enables energy consumption in all areas with substantial loads to be measured and monitored? Do energy meters support assessment of energy consumption trends, profiles and comparison with benchmarks?
#Has water sub metering been installed which enables water consumption in all areas with substantial consumption to be measured and monitored? Do water meters support assessment of water consumption trends, profiles and comparison with benchmarks?
#Is water and energy consumption monitored and reported to senior management on a regular basis?

===Facilities management manual===
A facilities management manual provides technical detail on all aspects of the building and how they should be maintained and managed. It is useful because it provides a repository of knowledge and information that can be used by facilities managers and their staff to ensure that health facilities are effectively managed and maintained.

#Has a detailed facilities management manual been developed for the health facilities? Does this include a detailed schedule for maintenance and other checks on equipment such as lighting, pluming fittings and HVAC
#Does the facilities management manual refer to a full set of as-built drawings and equipment manuals? Have a full set of hard copy and electronic copy as-built drawings and manuals been provided?
#Have facilities managers in the building had a full induction on the building’s systems and the facilities management manual?
#Does the facilities management manual get regularly reviewed and updated to reflect upgrade and renovations details.

===Senior management commitment===
Effective management of facilities can be supported by senior management commitment. Regular reporting on facilities performance such as energy and water consumption serve to ensure that management is aware of these issues and are likely to ensure that the appropriate mandate and resources are in place to improve this.

#Have facilities management policies in relation to sustainability been developed? For instance, are there policies or guidance on how energy and water consumption will monitored and managed?
#Have facilities management policies or guidelines been endorsed by senior management? Is there are requirement for facilities management to report on facilities performance on a regular basis to senior management?

==LOCAL ECONOMY==

===Objective===
The building supports the local economy

===Introduction===
The construction and maintenance health facilities are a significant investment by government. This investment, if considered carefully, can be used to support the local economy and employment. This is done by specifying local products and services from the local area.

Ensuring that health facilities support the local economy has a wide range of benefits including:

*Increased local employment
*Increased local capacity for new construction and maintenance of facilities

===Local economy in health facilities===
Supporting the local economy can be achieved in new facilities by understanding the nature and type of local building product suppliers and where appropriate specifying these in the building. Similarly understanding the capacity and skills of local contractors can be used to ensure that these are developed and enhanced by being engaged in the construction and maintenance of health facilities.

===Criteria===
Supporting the local economy in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key waste considerations have been addressed. These are outlined below.

===Small enterprise support===
The waste and emissions in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key waste considerations have been addressed. These are outlined below.

Minimizing irrigation water requirements can be used to reduce water consumption. The following measures can be considered:

#Are small enterprises provided with opportunities to tender for relevant construction and maintenance contracts? Can local, small enterprises be given preference in the awarding of work?
#Where local small enterprises have limited capacity and experience, can they be supported by encouraging partnerships with more established and larger enterprises?

===Material and component procurement===
The specification of local materials and components in the construction of health facilities can provide a significant incentive to local suppliers and manufacturer to develop appropriate products and capacity. This in turn provides local employment and can ensure that maintenance and repairs at the facilities can be carried out more quickly and cost effectively.

#Has a review of local materials and components been carried out?
#Have local materials and components been specified?

===Construction employment===
The construction industry can employ significant numbers of people. This can be supported through designs, specifications and labour intensive construction techniques which can be used to construct facilities without significant cost or time implications. Local construction employment improves the local economic impact of projects and ensures that there is local capacity to undertake repairs and maintenance of facilities.

#Is construction employment a key consideration in the design, specification and construction of the facility?
#Have opportunities to create local employment been sought and developed through the project?

==PRODUCTS AND SERVICES==

===Objective===
The building supports use of more sustainable products and services

===Introduction===
Products and services used in health facilities have a range of impacts and planning can be used to maximise beneficial impacts and avoid negative impacts. The construction and maintenance health facilities are a significant investment by government. This investment, if considered carefully, can be used to support the local economy and employment. This is done by specifying local products and services from the local area.

Ensuring that health facilities support the more sustainable products and services has a wide range of benefits including:

*Reduced waste
*Increased support for sustainable choices and options for health facility users

===Products and services in health facilities===
Supporting the local economy can be achieved in new facilities by understanding the nature and type of local building product suppliers and where appropriate specifying these in the building. Similarly understanding the capacity and skills of local contractors can be used to ensure that these are developed and enhanced by being engaged in the construction and maintenance of health facilities.

===Criteria===
Supporting the more sustainable products and services in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key product and service considerations have been addressed. These are outlined below.

===Local produce===
Impacts associated with transport and storage / refrigeration mean that produce imported from some distance away generally has significantly higher ecological footprints than local produce. Health facilities can therefore reduce ecological footprints associated with food through using local produce as far as possible.

#Is local produce used in preference to produce imported some distance away?
#Has the use of local produce been made a requirement in outsourced catering contracts?

===Vegetarian options===
Meat-based meals generally have significantly higher ecological food print requirements relative to vegetarian meals. Providing vegetarian options can therefore support reduced food impacts within health facilities.

#Are vegetarian options provided in catering establishments within the health facility?
#Has the provision of vegetarian options been made a requirement for outsourced catering contracts?

===Drinking water===
Waste streams can be reduced by providing alternatives to bottled drinking water. Drinking water can be provided through strategically located drinking fountains, as well as being supplied in reusable containers. A ready supply of drinking water also has health benefits.

#Is non-bottled drinking water readily and freely available throughout the health facility?

===Reuseable vessels===
Significant waste streams can be avoided through the use of reusable vessels. In particular disposable food and drink vessels can be avoided by providing reusable vessels. This option can be supported through provision of required storage and washing and facilities.

#Have reusable vessels been specified in preference to disposable containers, for services such as catering?
#Has adequate provision been made for reusable vessels in the form of storage and washing facilities?

==ACCESS==

===Objective===
The building supports access to facilities

===Introduction===
Current work patterns and lifestyles mean that many people have to access facilities such as banking, retail, childcare and communications on a regular basis. Ensuring that these facilities are within the health facility or within easy walking distance helps to avoid or reduce associated time and transport impacts.

Ensuring that health facilities support access to facilities has a wide range of benefits including:

*Reduced transport impacts
*Reduced time spent travelling to and from facilities

===Access to facilities in health facilities===
Supporting access to local facilities can be achieved through incorporating these into the health facility. Alternatively the health facility can be located near where these exist. It may also be possible to work with relevant service providers in order to provide these locally.

===Criteria===
Supporting access to facilities in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key access considerations have been addressed. These are outlined below.

===Banking===
Access to banking can be provided through formal banking facilities or through bank ATMs. This can be provided within the health facility or within easy walking distance of this.

#Are banking facilities available within the health facilities or within the local area?

===Grocery retail===
Grocery retail can be provided through local shops, supermarkets and markets. This can be provided within the health facility or within easy walking distance of this.

#Are grocery retail facilities available within the health facility or within the local area?

===Communication===
Access to telephone and internet can be provided through internet cafes or at stand alone kiosks. This can be provided within the health facility or within easy walking distance of this.

#Are internet and telephone facilities available within the health facility or in the local area?

===Café===
Access to catering facilities can be provided through cafes, restaurants or canteens. Refreshments should be affordable and accessible to both staff and health facility users. This can be provided within the health facility or within easy walking distance of this.
1. Is there an accessible, affordable café, restaurant or canteen within the health facility or in the local area?

===Childcare===
Significant waste streams can be avoided through the use of reusable vessels. In particular disposable food and drink vessels can be avoided by providing reusable vessels. This option can be supported through provision of required storage and washing and facilities.

#Is there a childcare facility within the health facility or in the local area?

==HEALTH==

===Objective===
The building supports a healthy and productive environment

===Introduction===
Health facilities by their definition aim to support health and well being in their users. In addition to medical care health can be promoted through beneficial environmental conditions including a plentiful supply of fresh air, views and optimum thermal comfort conditions. It is particularly important to avoid conditions and situations that may be harmful to human health.
Ensuring that health facilities support the health in facility users and construction workers services has a wide range of benefits including:

*Improved recovery rates for patients
*Reduced absenteeism associated with environmental conditions by health facility staff
*Reduce injury and absenteeism rates associated with dangerous or harmful working construction environments

===Criteria===
Ensuring construction and health facilities promote health can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that health promotion considerations have been addressed. These are outlined below.

===External views===
Views and a connection to the external environment improve internal environmental conditions and can help improve recovery rates and reduce employee absenteeism.

#Do health facility staff working areas have views to the external environment
#Do patient areas have views of the external environment?

===Daylight===
Day lighting can help reduce energy consumption associated with artificial lighting. It also improves internal environmental conditions for patients and health facility employees.

#Are health facility staff working areas well day lit?
#Are patient areas well day lit?

===Ventilation===
High levels of fresh air are important for human health and productivity. This can be provided through natural or mechanical ventilation. Where mechanical ventilation is used sufficiently high levels of external, fresh air should be provided and recirculated air should be avoided or minimized.

#If the condition of outside air makes it unfit for direct ventilation use, is it appropriately pre-treated and filtered by the ventilation system?
#Are health facility staff working areas well supplied with good quality outside air?
#Are patient areas well supplied with good quality outside air?

===Building materials===
Building materials can have negative impacts for human health associated with their extraction and manufacture. They may affect health in facilities, through for instance offgassing hazardous chemicals. Construction materials should therefore be screened to avoid products being used in health facilities that have negative impacts on human health.

#Has criteria been developed and applied for the selection and screening of building materials?
#Have all building materials that may off gas substances such as formaldehyde and volatiles organic components that may be harmful to human health been avoided?

===Contractor health and safety===
There are considerable health and safety risks in the construction industry. Considering health and safety in the design of health facilities can be used to reduce health and safety risks associated with construction and maintenance. Making provision for safe access to glass facades or to high level lighting helps to ensure that this can be installed, cleaned and maintained without undue health and safety risks. In addition, addressing health and safety comprehensively in contract and construction planning, procedures and processes can be used to eliminate many construction health and safety risks.

#Has contractor health and safety been considered as a key issue in the design of the building? Have construction risks been minimised through appropriate design risk assessments and mitigation?
#Have detailed construction plans, procedures and processes been developed to minimise risks where these may occur during construction?
#Has appropriate health and safety procedures been put in place to ensure that plans are implemented and monitored?

==EDUCATION==

===Objective===
The building supports education

===Introduction===
Education and on-going learning is increasingly been seen as an essential component of sustainable development and a competitive economy. This is recognised in health care through the requirement for health care professionals to under continued professional development (CPD). Education and on-going learning can be supported through technology and spaces within facilities that support this. Examples of this include training rooms and access to ICT and reading material. In addition well packaged
Ensuring that health facilities support the education has a wide range of benefits including:

*Improve ability by health facilities staff to keep up-to-date with new developments in health care
*Ability to attract and retain staff

===Criteria===
Ensuring construction and health facilities promote education and on-going learning can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that education and on-going learning considerations have been addressed. These are outlined below.

===Contractor education===
There are considerable health and safety risks in the construction industry. Considering health and safety in the design of health facilities can be used to reduce health and safety risks associated with construction and maintenance. Making provision for safe access to glass facades or to high level lighting helps to ensure that this can be installed, cleaned and maintained without undue health and safety risks. In addition, addressing health and safety comprehensively in contract and construction planning, procedures and processes can be used to eliminate many construction health and safety risks.

#Has contractor health and safety been considered as a key issue in the design of the building? Have construction risks been minimised through appropriate design risk assessments and mitigation?
#Have detailed construction plans, procedures and processes been developed to minimise risks where these may occur during construction?
#Has appropriate health and safety procedures been put in place to ensure that plans are implemented and monitored?

===Notice boards===
Notices are very easy and cost effective way of communicating information. They can be used to support education and awareness by drawing attention to new or important education. For instance, awareness and reminders about new health care policy, procedures and processes can be communicated. Notice boards have the benefit that they can be located where they will be seen by all personnel on a regular basis and are not reliant on a particular technology, such as email. This helps to ensure information can be communicated to all levels of staff within a health facility.

#Have notice boards been located in key locations in the health facility where they can be used to communicate key information to facility staff and users?
#Have communication and education plans been developed that will ensure that notice boards will be updated throughout the year with relevant notices and information?

===Space for learning===
Formal training can be supported through access to training rooms. More informal on-going learning can be provided through access to resource centres where learning material, computers and the internet can be accessed.

#Are there appropriately sized and equipped facilities to accommodate formal training?
#Are there appropriately sized and equipped facilities to support informal on-going learning by staff?

===Employee induction===
Employee induction refers to awareness training provided to new employees. This can be used to support sustainability by developing awareness in health facility staff about sustainable building systems and how they should be used. This may include aspects such as lighting and HVAC operation as well as recycling procedures.

*Have employee induction processes been developed?
*Do these include detailed information on systems in the building that aim to support sustainability?

===Building user manual===
Building user manuals aim to complement employee induction processes by providing easily accessible and understanding information related to a facility in order to support user behaviour that support sustainability.

#Has a building user manual been developed?
#Is this readily accessible and easy to use?

==INCLUSION==

===Objective===
The building is inclusive of diversity in population

===Introduction===
Design for inclusion helps to ensure that facilities can be used by all users including older people, sick people, people with children and people with disabilities. Inclusive design also often means that facilities are safer and easier to use. In health facilities both of these aspects are particularly important.

Ensuring that health facilities are inclusive has a wide range of benefits including:

*Less requirement to replicate facilities
*Facilities that are easier and safer to use

===Criteria===
Ensuring health facilities are inclusive can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key inclusion considerations have been addressed. These are outlined below.

===Accessible transport===
Inclusive access to health facilities is an important consideration. This means ensuring that people who may be ill, infirm, old or have disabilities are able to access health facilities easily. This requires accessible routes from places for work and accommodation to the facilities and often requires easily accessible local public transport systems. This can be p

Ensuring that health facilities support the education has a wide range of benefits including:

#Are there regular, affordable and efficient local transport systems?
#Can these be accessed readily from health facility users’ accommodation and places of work?
#Can the health facility be accessed readily from public transport?
#Is public transport provision inclusive?

===Environmental access===
Facility design and management for environmental access can be used to ensure that health facilities are inclusive. This requires a comprehensive approach that ensures that access consideration are effectively integrated into all aspects of health facility design. Guidance on this aspect is provided in the IUSS d

#Does the facility design fully comply with the IUSS environmental access requirements?
#Are systems and management in place to ensure that environmental access standards are maintained during operation?

===Access to affordable accommodation===
There is an increasing shortage of affordable accommodation in many South African cities. This can have a range of negative impacts including the requirement for long distance commuting, disrupted family life, and reduced family budgets for non-transport related costs such as education and health. Increasing local affordable accommodation can be achieved through partnership agreements with local developers and social housing organizations.

#Is there affordable local accommodation for health facility staff?
#If this does not exist, have initiative been taken to develop this with developers and or social housing institutions?

==SOCIAL COHESION==

===Objective===
The building supports social cohesion

===Introduction===
Social cohesion refers to the extent to which individuals within a community understand, collaborate, trust and work together. It is valuable because it enables collective knowledge and resources to be used more effectively and efficiently to support common goals. Within a health facility improved social cohesion can support improved healthcare with fewer resources by sharing and using these more effectively. It can also support improved communication and cooperation within health teams and therefore improving levels of service and reducing wastage and mistakes.

Ensuring that health facilities support social cohesion has a wide range of benefits including:

*More efficient and effective use of resources
*Improved communication and coordination
*Reduced wastage

===Criteria===
Ensuring health facilities support social cohesion can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key social cohesion considerations have been addressed. These are outlined below.

===Shared used of facilities===
Shared use of facilities helps to ensure that valuable facilities are well used and beneficial impacts are experienced across a wider range of people. Capital and operating costs of the facility may also be reduced as these are shared between a larger number of organizations or individuals. This concept can be applied to health facilities in a range of different ways. For instance, sharing arrangements with a local sport club or fitness center can be used to enable a health facility to use swimming pools and other facilities for rehabilitation without having the ongoing costs and management of this facility.

#Have shared use, and possibly development, of facilities been explored with local organizations?
#Have appropriate design considerations been put in place to ensure effective shared use of facilities?
#Have appropriate management considerations been put in place to ensure effective shared use of facilities?

===Social spaces===
Social spaces, such as canteens, cafes and common rooms can play an important role in the life of organization. They not only provide a respite from work environments they also provide a space for relaxed social interaction. This interaction and the relationships and communication networks created can may a significant impact in improving organizational effectiveness and responsiveness. In health care facilities this is a valuable resource which helps to motivate individuals and build strong teams that are able to provide effective and responsive health care.

#Have an appropriate number and type of social spaces been provided within the health facility?
#Will these facilities support easy social interaction within and between health teams, as well as cross health facility staff structures?

===Stakeholder involvement===
Involving people in decisions on issues will have an impact on them is a useful way of helping ensure that there is support for an initiative or a process. Structured involvement of stakeholder helps to ensure a shared understanding can be developed, joint decisions made and there is efficient and effective implementation. For instance, within a health facility, effective involvement of key stakeholders can help goals such as improved energy efficiency through ensuring that managers, building technical staff and health services staff understand the goal, the means that this will be achieved and can see their role in supporting this.

#Has there been appropriate stakeholder involvement in the design of health facilities?
#Has there been appropriate stakeholder involvement in the management of health facilities?

==REFERENCES==

#[http://www.cidb.org.za/publications/Documents/Greenhouse%20Gas%20Emission%20Baselines%20and%20%20Reduction%20Potentials%20from%20Buildings%20in%20South%20Africa.pdf CIDB, 2009. South African Report on Greenhouse Gas Emission Reduction, Potentials from Facilities, A Discussion Document. Construction Industry Development Board. Page 22].
#. DEAT, 1995. Urban Open Space: Guidelines for effective management. Discussion document based on Agenda 21 and the RDP
#[https://www.environment.gov.za/sites/default/files/gazetted_notices/nema_guidelines_g33333gen654_0.pdf DEAT, 1998. National Environmental Management Act. Department of Environment and Tourism, Pretoria. Chapter 1.]
#DEAT 2009, State of the Environment Report Accessible from http://soer.deat.gov.za/themes.aspx?m=387
#DEAT, 2009a, The National Climate Change Response Policy. Department of Environment and Tourism, Pretoria. Page 8.
#DEAT, 2009b, The National Climate Change Response Policy. Department of Environment and Tourism, Pretoria. Page 14
#DEAT, 2009c, The National Climate Change Response Policy. Policy Department of Environment and Tourism, Pretoria. Page 20.
#EMM and GDACE, 2007. Environmental Management Framework for Ekurhuleni. Ekurhuleni Metropolitan Municipality and Gauteng Department of Agriculture, Conservation and the Environment
#Hewitson, B. Engelbrecht, F Tadross, M. and Jack, C., 2005. General conclusions on development of plausible climate change scenarios for southern Africa, in: R. E. Schulze (ed.), Climate Change and Water Resources in Southern Africa: Studies on Scenarios, Impacts, Vulnerabilities and Adaptation, Water Research Commission, WRC Report 1430/1/05, Pretoria, South Africa.
#IPCC, 2007. Climate Change 2007, Synthesis Report. Inter Governmental Panel on Climate Change. 2007.Page 7
#SEA 2006, State of Energy in South African Cities. Sustainable Energy Africa. Cape Town.
#South African Bureau of Standards. 2007. SANS 204 Energy Efficiency in Facilities
#WWF 2006. Living Planet Report 2006.World Wildlife Fund. Accessed from www.panda.org.

==APPENDIX A: SUSTAINABILITY INTEGRATION PLANS==
 
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[[Category:Crosscutting Issues]]

Sustainability

2021-05-04T12:33:41Z

Tmojanaga: /* REFERENCES */

==INTRODUCTION==

==Purpose==
This document has been developed for the Department of Health to ensure that sustainable development is integrated into to planning and design of health facilities. The document defines sustainable development and outlines the implications of this for the built environment. It provides objectives and criteria that can be used in the development health facilities in South Africa.

==Background==
The Department of Health wish to support sustainable development in South Africa and ensure that there is an appropriate balance between economic development, social integration and protection of the environment.
Global Warming and South African legislation and policy now make it imperative that built environment projects address sustainability. However, there is limited South African guidance on how sustainable development can be integrated with built environment projects. There is also the perception that addressing sustainability in facilities will be expensive and complicated.
This document provides guidance and checklists that can be used to support the integration of sustainability into health facilities. It shows that by addressing sustainability early in projects, additional costs can be minimised and innovative, high-performance solutions that benefit society, the economy and the environment can be achieved. It also shows that achieving more sustainable facilities need not be complex but can be based on robust, sensible and simple measures.

==How to use this document==

This document provides a framework that can be used to inform the development of health facilities. It can be used in the following ways:

*'''Awareness''': This document can be used to increase awareness about sustainable development and the need to address this in built environment projects. This will lead to more rigorous debate on development options and support more innovative and sustainable solutions.

*'''Setting sustainable development targets''': This framework can be used by a development team to set explicit and challenging sustainable development targets for projects. This is done by setting quantified targets against criteria in the document and putting in place systems to ensure that these are achieved.

*'''Self-assessments''': This framework can also be used for self-assessment and to ascertain the performance of development proposals. To carry this out refer to the Facility Recommended Compliance sheet and Compliance Checklist at the end of the document. This enables different health facility development proposals to be evaluated in terms of recommended compliance. Assessment using the criteria can also inform the design process by being used to evaluate different development options. This enables optimal solutions to be developed in an iterative and efficient way.

*'''Coordinated development''': Some criteria in the document may appear not to be in the remit of, or possible in, a single development. These criteria however can be achieved through partnerships and local collaboration. This framework can be used bring together the key role players in order to develop integrated plans that enable key sustainable development objectives to be achieved.

==Structure of the guideline==
The document has the following structure:

*'''Implementing Sustainable Development''': This section provides a description of sustainable development and translates this into specific sustainable development objectives for the built environment.

*'''Built Environment Sustainable Development Objectives''': In this section more detailed guidance and checklists are provided for each of sustainable development objectives listed in the section above.

*'''Sustainability Integration Plans''': This provides guidance on plans and a structure that can be used to integrated sustainability in design and operational processes.

==IMPLEMENTING SUSTAINABLE DEVELOPMENT==

===Introduction===
South Africa faces a range of social, economic and environmental challenges. HIV/AIDs has resulted in a life expectancy dropping from 67 years in 1998 years to around 47 years currently. Unemployment is estimated to be 27% and climate change is likely to lead to increasing water stress, reduced food security and loss of species and ecosystems (DEAT 2009).
Sustainable development, which aims to achieve social and economic improvements while reducing negative environmental impacts, can be used to address these challenges. Sustainable development however can be difficult to achieve. This is because a holistic and integrated approach is required and the development sector and in particular, the construction industry, operates in a highly fragmented way. In addition, the concept of sustainable development is still new and has not been adequately translated into practical actions that can be readily implemented.
This section defines sustainable development and translates this into key built environment objectives. It also describes the role of the built environment in creating environmental and other problems and shows how integrating sustainable development considerations into construction and the built environment can make a substantial contribution to improving the social, economic and environmental performance of the built environment.

===The environmental context===
Increasing carbon emissions from human activities and a reduction in the ability of the natural environment to absorb carbon dioxide is leading to an accumulation of greenhouse gases in the upper atmosphere. These gases trap more heat in the upper atmosphere leading to global warming and temperatures are predicted to increase by 2 - 6°C OC by the end of the century (IPCC, 2007). Estimates carried out for the City of Joburg indicate that temperatures in the next 50 years may increase between 2 and 3.5°C (Hewitson, Engelbrecht, Tadross, Jack, 2005).

Within Africa, South Africa produces the highest CO2 emissions and has one of the highest CO2 emissions per GDP in the world. In 2002, carbon emissions per capita in South Africa were 8.4tonnes/capita - higher than Western European averages of 7.9tonnes/capita (SEA 2006).
Global warming is likely to impact Africa particularly negatively. The National Climate Change Response Policy Developed by the Department of Environment and Tourism outlines the following impacts (DEAT 2009a):

*Agricultural production and food security in many African countries are likely to be severely compromised by climate change and variability. Projected yields in some countries may be reduced by as much as 50% in some countries by 2020 and as much as 100% by 2100. Small scale farmers will be most severely affected.

*Existing water stresses will be aggravated. About 25% o Africa’s population (about 200million people) currently experience high water stress. This is projected to increase to between 75-250 million by 2020 and 350-600 million by 2050.

*Changes in ecosystems are already being detected and the proportion of arid and semi-arid lands in Africa is likely to increase by 5-8% by 2080. It is projected that between 25 and 40% of mammal species in national parks in sub-Saharan Africa will become endangered.

*Projected sea-level rises will have implications for human health and the physical vulnerability of coastal cities. The cost of adaptation to sea level rise could amount to 5-10% of gross domestic product.

*Human health will be negatively affected by climate change and vulnerability and incidences of Malaria, Dengue fever, Meningitis and Cholera may increase.

===The contribution of the built environment===
Construction and the built environment make a substantial contribution to global warming and play a significant role most economies. Environmental, social and economic impacts attributed to the built environment at a global scale are outlined below.

*Consumes 40% of energy use,

*Consumes 17% of fresh water use,

*Consumes 25% of wood harvested,

*Consumes 40% of material use,
*Employs 10% of the world’s work force,

*Construction is the largest employer of micro-firms (less than 10 people),

*Facilities are typically located on the most productive land (Estimated to be 250 million hectares world wide, mostly on primary agricultural land).

In South Africa the built environment is directly responsible, through electricity consumption, for over 23% of South Africa’s carbon emissions (see table below). Vehicle-based infrastructure and transport planning has resulted in transport contributing to 16% of South Africa’s CO2 emissions and an additional 18mtCO2 per year, or about 4% of South Africa’s CO2 emissions, come from the manufacture of building materials (CIDB 2009).

Sector C02 Emissions

Commercial 10%

Residential 13%

Transport 16%

Industry 40%

Mining 11%

Other 10%

Total 100%

''Figure 1: South African carbon emissions per sector''

===Defining sustainability===
Recent work by the World Wildlife Fund contributes substantially to defining sustainable development by providing quantified minimum criteria for sustainability. In the 2006 Living Planet Report, sustainability is defined as achieving an Ecological Footprint (EF) of less than 1.8 global hectares per person and an Human Development Index (HDI) value of above 0.8 (WWF 2006).

===Ecological Footprint===
An Ecological Footprint is an estimate of the amount of biologically productive land and sea required to provide the resources a human population consumes and absorb the corresponding waste. These estimates are based on the consumption of resources and production of waste and emissions in the following areas:

*Food, measured in type and amount of food consumed,

*Shelter, measured in size, utilization and energy consumption,

*Mobility, measured in type of transport used and distances travelled,

*Goods, measured in type and quantity consumed.

*Services, measured in type and quantity consumed The area of biologically productive land and sea for each of these areas is calculated in global hectares (gha) and then added together to provide an overall ecological footprint. This measure is particularly useful as it enables the impact of infrastructure and lifestyles to be measured in relation to the earth’s carrying capacity of 1.8 global hectares (gha) per person.

===The Human Development Index===
The Human Development Index was developed as an alternative to economic progress indicators and aimed to provide a broader measure that defined human development as a process of enlarging people’s choices and enhancing human capabilities (United Nations Development Programme 2007). The measure is based on:

*A long healthy life, measured by life expectancy at birth,

*Knowledge, measured by the adult literacy rate and combined primary, secondary, and tertiary gross enrolment ratio,

*A decent standard of living, as measure by the GDP per capita in purchasing power parity (PPP) in terms of US dollars.

===South African EF and HDI figures===
The figures below show that South Africa has an ecological footprint of 2.1, above the maximum required of 1.8 gha and a human development index measure of 0.66, below the minimum of 0.8 required for sustainability.

Measure South Africa Sustainability Target
Ecological Footprint (gha) 2.1 1.8
Human Development Index 0.658 0.8
{| class="wikitable"
|+
!Measure
!South Africa
!Sustainability Target
|-
|Ecological Footprint (gha)
|2.1
|1.8
|-
|Human Development Index
|0.658
|0.8
|}

For South Africa to move towards sustainability there must therefore be an improvement in both the Ecological Footprint and Human Development Index performance. The built environment has a key role in supporting this improvement.

===The legislative and policy context===
South Africa has a range of legislation and policy that aims to protect the environment and support sustainable development. Key legislation supporting sustainable development includes the South African Constitution and the National Environmental Management. These are discussed briefly below.

===South African Constitution===
The South African Constitution contains a Bill of Rights that enshrines the rights of all people in South African and affirms the democratic values of human dignity, equality and freedom. The Bill has sections covering equality, human dignity, privacy, freedom of religious belief and opinion, environment, property, housing, healthcare, food, water and social security, children, education, language and culture. Through a section on equality, the Bill requires that all people have full and equal enjoyment of these rights and freedoms:

''Everyone is equal before the law and has the right to equal protection and benefit of the law.''

Equality includes the full and equal enjoyment of all rights and freedoms. To promote the achievement of equality, legislative and other measures designed to protect or advance persons or categories of persons, disadvantaged by unfair discrimination, may be taken.
Environmental rights in the Bill of Rights include the right to an environment that supports health and wellbeing. It also requires legislation to be developed to ensure that the environment is protected and that development that does occur is both sustainable, and justifiable:

===Environment===
Everyone has the right

a). to an environment that is not harmful to their health or well-being; and

b). to have the environment protected, for the benefit of present and future generations, through reasonable legislative and other measures that ¬

#prevent pollution and ecological degradation;
#promote conservation; and
#secure ecologically sustainable development and use of natural resources while promoting justifiable economic and social development.

Sustainable development and the protection of the environment is, therefore, a constitutional obligation and there is a requirement for ‘reasonable legislative and other measures’ to be put in place to ensure that this achieved. '''This document represents a measure taken by the Department of Health to achieve sustainable development.'''

===Carbon emission mitigation strategies===
South Africa is a signatory to both the United Nations Framework Convention on Climate Change (UNFCC) and the Kyoto Protocol. In order to address UNFCC commitments, the Long Term Mitigation Scenarios (LTMS) process was initiated in 2006 and completed in 2008. This formulated strategies to ensure that South Africa would reduce carbon emissions. Many of the mitigation strategies identified have implications on the built environment and these are outlined below (DEAT 2009b):

*Limits on less efficient vehicles

*Passenger modal shift
*Solar water heater subsidy

*Commercial efficiency
*Residential efficiency

*Renewables with learning

*Waste management

*Land use: afforestation

*Escalating CO2 tax

Following the LTMS process, key policy approaches were agreed on by the South African cabinet. These strengthen current energy efficiency and demand-side management initiatives such as environmental fiscal reform and carbon taxation which will penalize energy inefficient technology and provide for additional tax allowances of up to 15% for energy-efficient equipment.
The LTMS process however also showed that although significant emission reductions could be achieved through technology-based actions, these were not sufficient for the scale of change required and that adaptations in social behaviour would be required. (DEAT 2009c).The LTMS, therefore, proposed a number of people and building orientated measures that offered low-cost large scale mitigation impacts including:

*Social adaptation and changes in human habitation, urban planning and the built environmental

*Studies on the distance between work, home and other life functions

*Modal shifts to public transport and moves away from individual car owners towards the operation of shared vehicles

*Food production and consumption, as well as the localization of these activities

==Built environment sustainable development objectives==
The environmental context, legislation and potential future measures to reduce carbon measures make it clear that the built environment must change to support sustainable development. It also makes it clear that many of the conventional practices in the planning, design, construction and management of building must be substituted with improved more sustainable approaches.
In order to develop practical measures that can be integrated into the built environment, it is useful to set out built environment or development objectives that, together, would support sustainable development. These objectives are outlined below and form the starting point for the next sections of this document where more detailed criteria are provided.

===Environmental objectives===

*Energy: The building is energy efficient and uses renewable energy

*Water: The building minimises the consumption of mains potable water.

*Waste: The building minimizes emissions and waste directed to landfill

*Materials: Construction impacts of building are minimized
*Biodiversity: The building supports biodiversity

===Economic objectives===

*Transport: The building supports energy efficient transportation
*Resource Use: The building makes efficient use of resources
*Management: The building is managed to support sustainability
*Local Economy: The building supports the local economy
*Products and Services: The building supports use of more sustainable products and services

===Social objectives===

*Access: The building supports access to facilities

*Health: The building supports a healthy and productive environment

*Education: The building supports education
*Inclusion: The building is inclusive of diversity in population

*Social Cohesion: The building supports social cohesion

===Integrating sustainable development objectives into health facilities===
Integrating sustainable development objectives requires structured processes. These are described below in terms of design and operational processes.

===Design processes===
Addressing sustainability in designs for new health facilities can be achieved through the following steps:

'''Target setting:''' Challenging sustainability targets should be set for the building and agreed with all of the key stakeholders of the project including the design team, the facilities manager and the funder or owner of the building. Targets should take into account government policy and strategies as well as local and international best practice.

2. '''Design principles:''' Strategies and design principles required to achieve these sustainability objectives should be understood and established from the outset. For instance, energy targets may require passive environmental control strategies to be well understood and established from the outset. These strategies and their implications can be understood through analysis of best practice examples and precedents.

3. '''Integrated design:''' Once targets and design principles have been established, an integrated design process should be used to ensure that all aspects of the building work together to achieve the required performance. This requires the different disciplines to work closely together.

4. '''Testing:''' Throughout the design process, checks should be carried out to ensure that targets set will be achieved. This can be done through calculations, modelling and analysis which assesses performance against targets set. Where aspects of the design are found not to meet targets a re-evaluation of the design should be carried out and in an iterative and integrated way, improved, to ensure that performance achieves, or surpasses, targets set.

5. '''Detailed design and implementation:''' It is important to ensure that the principles set out in 2 above, are carried out in to detail otherwise this may affect operational performance. This includes, for instance, details such as appropriate locations for switches, labels and instructions.

6. '''Handover:''' On completion, effective processes should be followed to ensure that design intentions are carried through into building operation. This includes effective commissioning, handover and training processes which ensure that designers, subcontractors and suppliers transfer knowledge and skills to facilities managers required to ensure effective management of the building.

===Operational performance===
Addressing sustainability in existing or newly developed health facilities can be achieved through the following steps:

#'''Data''': Obtain operational performance data on your building for at least a full year. For energy, this can be obtained in the form of utility statements that indicate energy consumption in kWh.
#'''Benchmark''': The above data should be normalised so that it can be compared to benchmarks. This will indicate whether your facility is below or above benchmark performance. If performance is well over benchmark, further investigation should be carried out, as this indicates there is room for improvement.
#'''Walkthrough assessment''': A walkthrough energy assessment can be used to identify where obvious improvements can be made. Checklists are used as a basis for these assessment and they can be carried out by health facilities personnel with training or experience of the respective areas such as water and energy.
#'''Audit''': Where walkthrough assessments and benchmarking exercise indicate that a full audit is warranted this can be carried out. These audits provide detailed reports on interventions that can be carried out to improve sustainability performance in a facility.
#'''On-going operational performance''': A key component of improving sustainability operational performance, in combination with the steps above, is an on-going programme that improves performance. This includes detailed sustainability monitoring and reporting as well as day-to-day management processes required to optimise performance. Operational performance should be allocated to an individual who is required to report on this to senior management. Identified responsible persons should be provided with appropriate training, resources and incentives to achieve excellent energy performance.

==='''Sustainability integration plans'''===
The above processes can be supported through sustainability integration plans which present targets, strategies and monitoring process for each sustainability performance areas. The simplest form of this is illustrated in the table below and can be used for both design and operational processes.

Area Targets Strategy Monitoring
Sustainability performance area Sustainability targets and requirements Proposed strategy and processes Progress on achievement of targets
{| class="wikitable"
|+
!Area
!Targets
!Strategy
!Monitoring
|-
|Sustainability performance area
|Sustainability targets and requirements
|Proposed strategy and processes
|Progress on achievement of targets
|-
|
|
|
|
|-
|
|
|
|
|}



==ENERGY==

===Objective===
The building is energy efficient and uses renewable energy

===Introduction===
Energy is used in health facilities to operate equipment, heat water, and to ensure that required minimum lighting, ventilation and thermal comfort standards are met. In most existing South African building it is estimated that savings of up to 30% of energy consumption can be achieved at no or low cost. These savings can be considerably higher in new facilities were passive strategies, energy efficient equipment and renewable energy systems can be used.

Ensuring that health facilities are more energy efficient use renewable energy has a wide range of benefits including:

*Reduced carbon emissions and therefore global warming impacts

*Reduced impact of mains power outages

*Reduced negative health impacts of pollution from coal-fired power stations

*Reduced operational costs

*Improved internal environment where passive strategies such as day lighting and natural ventilation lead to improved internal conditions relative to mechanical ventilation and artificial lighting.

===Energy consumption in health facilities===
Energy in South African health facilities is largely sourced from electricity, however gas and coal may also be used in larger hospitals and some rural clinics rely on local renewable energy systems such as photovoltaic panels and solar water heaters. The proportions of energy use in a conventional South African hospital and clinic are shown in the pie charts below:
{| class="wikitable"
|+
!
!
|-
|Proportions of energy consumption in a typical South African hospital
|Proportions of energy consumption in a typical South African clinic
|}

Data on energy consumption and demand in South African facilities is not readily available. However the following table provides a number of benchmarks 1
{| class="wikitable"
|+
!Energy benchmark type
!Typical
!Good practice
|-
|Clinics
|
|
|-
|Energy consumption (kWh/m2.a)
|1
|1
|-
|Maximum demand (VA/m2)
|1
|
|-
|Renewable energy (kWh/m2.a)
|0
|
|-
|Hospitals
|
|
|-
|Energy consumption (kWh/m2.a)
|395 2
|1
|-
|Maximum demand (VA/m2)
|1
|
|-
|Renewable energy (kWh/m2.a)
|0
|
|}
 
===Design Criteria===
Highly energy efficient facilities are optimized and integrated solutions that respond closely to the local site, climate and required internal functions. It is therefore difficult to prescribe this in a set of specific design criteria; however a series of questions are outlined below which can be used to check that key energy considerations have been addressed.

===Design and operation===
Improving energy performance in health facilities requires plans, procedures and processes that ensure that sustainability is integrated effectively into design and operations of a health facility. This can be achieved through setting challenging targets and effective monitoring processes.

#Have challenging sustainability targets been set for energy?
#Have effective procedures been established to model and test performance throughout the design process to ensure that these targets are achieved?
#Have the effective monitoring and evaluation systems, including regular reporting to the client, been put in place to ensure targets are achieved?
#Have capacity and systems in the form of staffing, training, manuals, commissioning and monitoring processes been planned for and put in place to ensure that design targets are achieved in operation.

===Orientation===
Orienting facilities so that the long facades face North – South helps to reduce unwanted heat gains from low angle sunlight early in the morning and late in afternoon. Where there is no alternative but to have facades face East and West, appropriate solar shading should be provided to avoid glare and control solar heat gain.

1. Are the long facades of facilities orientated to face within 15 degrees of a North – South orientation?

2. Is glazing on West and East facades minimized?

===Building shape===
While building shape and form may generally be determined by the functions accommodated, building form can also be shaped to minimise energy consumption. Shaping built form to limit building depth (see below) ensures that interior spaces can be naturally ventilated and day lit. Built form can also direct prevailing breezes through the facilities, supporting cooling and ventilation. It can also be used to create comfortable external spaces.

#Does the form of the building respond to local climate and topography?
#Does the building shape support reduced energy consumption and help create comfortable internal and external spaces?

===Building depth===
Limiting building depth enables internal space to be day lit and naturally ventilated. This ensures that internal space may not need artificial lighting or mechanical ventilation for much of the day, reducing energy consumption.

#Are building depths less than 15m?

==='''Insulation'''===
Insulation, especially when combined with thermal mass can be used to maintain comfortable indoor conditions without significant use of mechanical equipment. Insulation can ensure that valuable heat gains from people, equipment and the sun can be retained in the building to support comfort during winter. It can also reduce unwanted heat gains from ambient conditions in summer.

#Do the building envelope U-values achieve or surpass minimum values outlined in SANS 204 (SABS 2008)?

==='''Solar shading and glazing'''===
Glazing is usually the most vulnerable area of a building envelope and high heat losses and gains can be experienced through this component. It is therefore important to design glazing and devices which enable light and heat flow to be controlled.

#Is the glazing to wall ratio compliant with SANS 204 (SABS 2008)?
#Is solar shading compliant with SANS 204 (SABS 2008)?
#Has glazing with appropriate U-values, visual transmittance and solar heat gain coefficients been selected?

===Opening areas===
Opening areas within the building envelope such as doors and windows can be used to naturally ventilate the building. In general, it is advisable to provide for openings even in facilities that are mechanically ventilated and cooled as this enables them to be occupied and used in the event of a power cut.

#Are opening areas located to support effective natural ventilation?
#Is the area of openings provided compliant with SANS 10400 XA:2011?

Air tightness

Uncontrolled infiltration and airflow through the building envelope can affect comfort and increase heating and cooling loads in the building.

#Has careful detailing and specification been used to minimise infiltration in the building.
#Has a plan for rigorous construction supervision been put in place to ensure that building envelopes are air tight?

===Mechanical systems===
As far as possible mechanical cooling, heating and ventilation should be avoided. If this is not possible, a mixed mode operation should be selected. Mixed mode operation use mechanical system when ambient and internal conditions require this, but otherwise rely on passive systems to maintain thermal comfort and meet ventilation rate requirements. In particular circumstances mechanical cooling, heating and ventilation may be required for much of the year.

#Can the building or most of the spaces be passively cooled, heated and ventilated without the requirement for mechanical systems?
#If the application of passive systems will not achieve an acceptable number of annual comfort hours, can complementary mechanical systems be introduced to meet the comfort and ventilation requirements?
#Where zones exist within a facility that are not tolerant of passive ventilation and comfort systems, can a zoned mixed mode ventilation strategy be adopted?
#Where mechanical systems have been used has a rigorous exercise been undertaken to identify the most appropriate and energy efficient system?
#Where mechanical systems have been used do these include features that help reduce energy consumption such as:

a. An economy cycle

b. Controls that enable easy systems adjustments in order to benefit for seasonal and occupancy changes.

===Equipment===
As equipment used in building can consume large amounts of energy, the energy efficiency of equipment and energy ratings should be a key consideration. In addition, controls that ensure equipment is switched off when not in use should be specified.

#Is energy efficiency a key consideration in the selection of equipment?
#Is benchmarking energy consumption or energy rating used to support the selection of equipment?
#Are the controls provided for equipment easy to use and do they ensure that equipment is off when not required?

===Internal lighting===
Ensuring adequate lighting levels may be a key consideration in many spaces within health building. This should however be achieved in the most energy efficient way. Lighting is rapidly becoming more energy efficient and there are increasingly sophisticated controls.

#Is energy efficiency a key consideration in the selection of lighting?
#Has a rigorous evaluation process, including lighting power density calculations, been undertaken to ensure that the selected lighting system is highly energy efficient?
#Have appropriately sized lighting zones (ie under 100m2) been designed to avoid lighting being on where it is not required.
#Are lighting switching arrangements easy to use and encourage users to switch off lighting when not required?
#Are motion sensors used to switch lighting off in areas such as store rooms and meeting rooms when these are not used?
#Are daylight sensors used to switch lighting off in areas where these is adequate daylight? Areas with good daylight are usually found within a zone of about 6 m from external windows.
#Can light harvesting techniques and systems be incorporated in the design solution?

===External lighting===
Concerns about security often result in highly lit external areas. While security and building access requirements must be met, external lighting should be designed to be as energy efficient as possible.

#Are only areas that specifically require external lighting included?
#Has external lighting been provided as close to the area that requires lighting as possible and directed in order to avoid losses and light pollution?
#Are photo sensors, motion sensors or timers used to ensure that lighting is only on when required?

===BMS system===
Building Management Systems (BMS) should be used in complex building with complex equipment and systems. A BMS enables different systems to integrated and controlled and can support energy efficiency

#Has a BMS been used to coordinate and integrate systems, where complex systems are used in a large building?
#Is the BMS easy to use and understand?
#Is there local training and support for the BMS>
#Is the BMS system developed to open protocols and standards?
#Does the BMS include features that support energy efficiency such as:

a. Easy access to equipment schedules so that these can easily be changed to suite occupancy patterns.

b. Reminders to ensure that BMS operator tune building systems for greatest energy efficiency. For instance the system may provide a reminder to change air conditioning set points to match seasonal changes.

c. Reporting on water and energy sub metering and related equipment schedules.

===Sub metering===
An appropriate sub-metering system enables effective energy management. A facilities manager can see how much energy is used in different areas or uses in the facility. Sub-meters also show when and how energy is used through for instance energy profiles which show energy consumption and demand over time.

#Has an energy sub metering design been developed that will monitor all of the main energy uses in the facility?
#Is energy management data provided in formats and reports that can be easily understood and analyzed to support improved energy management?
#Does the system provide energy management report that can be used by both facilities managers and senior managers to improve energy efficiency in the facility?

===Renewable energy===
Increasingly renewable energy is becoming a competitive alterative to ESKOM supplied power. It also has the advantage that it increases the energy autonomy and independence of facilities, allowing these to operate even when there are mains power cuts.

#Are solar water heaters used to heat water in the facility?
#In areas with high quality, reliable sunlight, are photovoltaic systems used to reduce the reliance on ESKOM power?
#In areas with high quality, reliable wind, are wind turbines used to supplement to reduce the reliance on ESKOM power?

==WATER==

===Objective===
The building minimises the consumption of mains potable water.

===Introduction===
Water is used in health facilities for cleaning equipment, utensils and facilities, laundry, irrigation, food preparation and for drinking. In most existing South African health facility it is possible to reduce mains potable water consumption at no or low cost. These savings can be considerably higher in new facilities where water efficient technologies, grey water and rainwater systems can be used.

Ensuring that health facilities are more water efficient has a wide range of benefits including:

*Reduced water consumption and associated negative environmental impacts
*Reduced impact of mains water shortages or outages
*Reduced operational costs

===Water consumption in health facilities===
Water in South African health facilities is largely sourced from municipal potable water supply, however in some areas water may come from a rain water tanks or a borehole. The proportions of water use in a conventional South African hospital and clinic are shown in the pie charts below:
{| class="wikitable"
|+
!
!
|-
|Proportions of water consumption in a typical South African hospital
|Proportions of water consumption in a typical South African clinic
|}



Data on energy consumption and demand in South African facilities is not readily available. However the following table provides a number of benchmarks 1
{| class="wikitable"
|+
!Water benchmark type
!Typical
!Good practice
|-
|Clinics
|
|
|-
|Water consumption (kl/m2.a)
|1
|1
|-
|Hospitals
|
|
|-
|Water consumption (kl/m2.a)
|70 2
|1
|}
 

===Criteria===
The consumption of mains potable water in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective performance requirements within the health facility; however a series of questions can be used to check that key water considerations have been addressed. These are outlined below.

===Wash Hand Basin Taps===
Controlling and reducing water flows in wash hand basin taps can be used to reduce water consumption.

#Are wash-hand basin tap flow rates should not exceed 6L/minutes?
#Are passive infra-red (PIRs) or push-button controls used to limit the duration of flows?
#Has legionella control been considered when designing for low flow and systems and where existing system are made redundant?

===Toilets===
Reducing flush rates in water-borne sanitation can be used to reduce water consumption.

#Have WC flush rates been specified that do not exceed 6L/flush?
#Have dual flush controls can be used to ensure that reduced flush rates can be used when full flushes are not required?

===Showerheads===
Controlling and reducing water flows in showers can be used to reduce water consumption. The following measures can be considered:

#Have shower head flow rates been specified to not exceed 10L/minute?
#Are push-button type controls used to limit the duration of flows?
#Has legionella control been considered when designing for low flow and systems and where existing system are made redundant?

===Irrigation===
Minimizing irrigation water requirements can be used to reduce water consumption. The following measures can be considered:

#Are locally indigenous species (species found in the local area) used to minimise irrigation requirements?
#If irrigation is required, are highly efficient water delivery systems, such as a drip irrigation linked to soil moisture probes, used to minimise irrigation requirements.
#Has grey water been used to avoid the use of potable water for irrigation?

===Grey water systems===
Grey water systems reduce mains potable water consumption by reusing lower quality water within the facility. Examples of this are where waste water from showers and wash hand basins is captured and reused to flush toilets. Other sources of grey water include waste water from laundries and HVAC systems. Grey water systems however are potentially hazardous to human health, particularly in health facility environments. In particular, grey water which is left to stand for over 36 hours or is contaminated by food or similar waste is considered as blackwater and requires the same treatment as sewage. Therefore, grey water systems should only be designed, implemented and operated by appropriately competent people. Potential grey water applications in health facility environments are described below:

*Wash hand basin and shower waste water: Waste water from wash hand basins and showers can be directed to a grey water system and then used to flush toilets or for landscape irrigation.
*Vehicle wash: Waste water from vehicle waste can be reused to wash vehicles for up to 3 or 4 times. After this it can be disposed of or used for irrigation.
*HVAC plant: It may be possible to use waste water from HVAC systems for irrigation or to flush toilets. To ascertain if this is possible investigations should be carried out with the HVAC manufacturer and grey water specialists.

The following considerations in relation to grey water systems should be made:

*Have significant sources of grey water from, for instance, showers and wash-hand basins, been captured in a grey water system?
*Are grey water usage points appropriately labelled to prevent unsafe consumption.
*Will this grey water be used for irrigation or to flush toilets in order to significantly reduce portable water consumption?
*Is the proposed grey water system easy and cost effective to maintain?
*Have as many of the potential health hazards associated with the system been eliminated?

===Rain water systems===
Rain water systems store water captured from roofs or hard landscape surfaces. This water is then available for irrigation, to flush toilets or for cleaning. In large facilities very substantial amounts of water can be captured and used to reduce mains potable water consumption. A number of different types of systems are described below:

*Roof rainwater harvesting: Rainwater from roofs is directed to tanks and stores. Usually a proportion of initial run-off is directed to waste as it may have picked up dust and other debris. This system is the most common and generally has the lowest cost as rainwater tanks can be installed above ground surface.
*Hard surface rain water: This system captures storm water run-off from hard surfaces such as game pitches, paths and car parking. This type of system generally requires some form of filtration to remove debris, and in the case of car parking, oil wastes. Tanks are usually sub-surface.
*Landscape surface run-off capture: Surface run-off from soft landscaping can be captured and reused. This is sometimes used as part of an onsite storm water retention strategy. The disadvantage of this system is that the resulting water quality can be poor as debris and silt may be picked up. The filtration and maintenance requirements are therefore more stringent.

The following considerations in relation to rain water systems should be made:

#Have significant sources of rain water from roof and hard surfaces been captured in a rainwater harvesting system?
#Will this rain water be used in functions such as irrigation or to flush toilets in order to significantly reduce portable water consumption?
#Is the proposed rainwater harvesting system easy and cost effective to maintain? Have as many of the potential health hazards associated with the system been eliminated?

==WASTE==

===Objective===
The building minimizes waste directed to landfills.

===Introduction===
Waste in South African health facilities is largely directed to landfill sites. Not only does this use up valuable land, but can also lead to air, soil and water pollution if not waste is not disposed of correctly. In addition, this waste also consists of valuable resources that could be easily reused and recycled. Recycling and reusing materials not only reduces energy and resource consumption but can also create jobs and additional revenue streams.

Ensuring that health facilities minimise waste and reuse and recycle waste products are as follows:

#Reduced loss of land area to landfill
#Reduced energy and resource consumption
#Potential to create jobs and small enterprises

===Waste production in health facilities===
Waste in South African health facilities is largely directed to landfill sites. However in some area waste may be disposed of by local recyclers. The proportions of waste generated use in a conventional South African hospital and clinic are shown in the pie charts below:
{| class="wikitable"
|+
!
!
|-
|Proportions of waste in a typical South African hospital
|Proportions of waste in a typical South African clinic
|}

Data on waste in South African facilities is not readily available. However the following table provides a number of benchmarks 1
{| class="wikitable"
|+
!Waste benchmark type
!Typical
!Good practice
|-
|Clinics
|
|
|-
|Waste production (kg/m2.a)
|1
|1
|-
|Proportion of waste recycled or reused
|10%
|
|-
|Hospitals
|
|
|-
|Waste production (kg/m2.a)
|1
|1
|-
|Proportion of waste recycled or reused
|10%
|
|}

===Criteria===
Waste in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that key waste considerations have been addressed. These are outlined below.

===Provision for recycling===
Recycling can be encouraged by developing systems that make this easy. This includes providing easy-to-use receptacles for different types of waste and providing space in the right locations so that waste can be stockpiled into worthwhile quantities for a recycler to collect.

#Are there appropriate waste receptacles at the waste source to enable waste to be disposed of easily?
#Are there adequate number and type of waste receptacles at source to ensure that the value of waste is not reduced as a result of wastage or mixing of waste? For instance, clean waste paper can be spoilt if mixed with food waste.
#Has adequate storage space been provided in an appropriate location for the different recycling waste streams so that this waste can be stockpiled and easily accessed recycling contractors?

===Engagement with local recyclers===
Engaging with local recyclers earlier in the development of a new or refurbished facility can be used to understand the recycling process and the key requirements to make this effective.

#Have all the potential waste streams been identified? These include paper, cardboard, tin, glass, plastic, timber, electrical appliances etc?
#Have appropriate associations and local recyclers related to each of these waste streams been engaged with a view to ensuring that appropriate provision and systems are put in place to maximised recycling.

===Engagement with suppliers===
Engaging with suppliers can be used to reduce waste and transportation impacts. Waste and transportation impacts can be reduced through reduced use of packaging, use of reusable containers and optimized logistic supply chains.

#Have all suppliers of substantial goods and services to the health facilities been identified? Have these been engaged in relation to transportation and packaging with a view to minimising impacts in these areas?
#Has provision been made to reduce packaging waste and transport impacts through aspects such as increased space allowances for releasable containers and storage of products?

===Construction waste===
Construction is a major source of landfill waste. Waste from construction however can usually be easily reduced through explicit planning and monitoring processes.

#Has was construction waste minimization and recycling been included as specific requirement within tender and contract documents?
#Has the contractor been asked to develop a construction waste management plan in order to minimise waste? Does this plan include specific construction waste management targets ie 50% of all waste on site will be recycled? Have the parties responsible for implementing the plan been identified clearly and have they been given the mandate and resources to implement the plan? Has an appropriate monitoring and evaluation systems been put in place to ensure targets are achieved?

==MATERIALS==

===Objective===
Construction impacts of building are minimized

===Introduction===
Materials used in new facilities and the refurbishment of facilities can have significant impacts. Materials may be mined, processed, manufactured and transported before being incorporated in facilities. The extent and nature of the impacts of these stages varies widely depending on the material. The selection of materials and products to be used in facilities therefore is important in reducing negative environmental impacts.

Careful selection of construction materials used in health facilities has the following benefits:

*Reduced land and mining impacts
*Reduced environmental and health impacts from manufacturing processes
*Reduced transportation impacts
*Reduced material use
*Increased use of local sustainable materials

===Material use in health facilities===
Materials are used to construct South African health facilities and largely found in the building structure and envelope. More specialist materials and products such as refrigerants are found in equipment and systems within the building. The source and processes associated with construction materials and products have a wide range of impacts. It is therefore important to understand and confirm these with respective suppliers in order to select and specify materials and components with the least negative impacts.

===Criteria===
Material and component selection in health facilities can be addressed developing criteria list, communicating this to suppliers, and using this as a basis for specification and design. The nature of these criteria will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that key material and component considerations have been addressed. These are outlined below.

===Building reuse===
Using existing facilities instead of building new avoids or reduces the requirements for construction materials and therefore the impacts associated with extracting, manufacturing and transporting these. In addition, existing facilities are usually part of the urban fabric and already serviced with electricity, water, roads and public transport. Increasing the intensity of use of this fabric increases its efficiency and avoids the requirement to replicate this elsewhere. Therefore, in most circumstances it is preferable to reuse and refurbish existing facilities rather than build new facilities.

#Can the existing facilities continue to be used? If necessary, can these be refurbished and expanded rather than building a new facility?
#Are there other existing facilities that can be used? Can these be readily adapted for health use rather than constructing new facilities?

===Contribution to Global Warming===
Construction materials can contribute to global warming through carbon emissions associated with large amounts of energy used in their extraction, processing and transportation. This is referred to as embodied energy. Other materials such as refrigerant can contribute directly to global warming if they are released or leak into the atmosphere. Using existing facilities instead of building new avoids or reduces the requirements for construction materials and therefore the impacts associated with extracting, manufacturing and transporting these. In addition, existing facilities are usually part of the urban fabric and already serviced with electricity, water, roads and public transport. Increasing the intensity of use of this fabric increases its efficiency and avoids the requirement to replicate this elsewhere. Therefore, in most circumstances it is preferable to reuse and refurbish existing facilities rather than build new facilities.

#Refrigerants: Where refrigerants are being used in HVAC systems, cold rooms or in fire suppressions sytems have refrigerants with the lowest Global Warming Potential (GWP) and Ozone Depleting Potential (ODP) impacts been selected?
#High embodied energy materials: As far as possible, have construction materials with low embodied energy such as timber been selected? Where it is not possible to use these type of materials and high embodied energy materials such as cement and aluminium have to be use have the quantities of these materials been minimised?

===Reused materials or materials with recycled content===
Construction materials that are reused or have recycled content have less energy associated with their manufacture than equivalent new materials. Where possible, it is therefore preferable to reuse materials that may have already been used in another building or to select materials with recycled content.

#Are there materials from another building that is being demolished that could be reused? Aspects that can be reused include structure steel elements, facades, demountable structures such as carports, and building components such as windows and doors. Crushed concrete from demolished structures can also be used as aggregate in new construction.
#Have materials with recycled content been specified in preference to materials without any recycled content? Can the supplier / manufacture confirm the reduced environmental impacts of their recycled content product relative to new products?

===Reduced material use===
The quantity of construction materials used in facilities can be reduced through avoiding material use, using materials more intelligently and using materials for more than one use.

#Avoided material use: Have materials been avoided where these are not required? For instance, can ceilings and plastering be avoided through better concrete finishes? Can improved floor finishes be used to avoid the requirement for carpets and tiling? Can the use of passive systems reduce the requirement for ducting and plant?
#Intelligent material use: Can quantities of materials be reduced through different designs and specifications? For instance, can structural strategies such as pre-tensioning concrete slabs and waffle slabs be used to reduce concrete requirements? Can material use and wastage be reduced through use of precast elements?
#Dual plus use: Can materials be used for more than one purpose? For instance, can photovoltaic panels be used as a roofing material as well as to generate material?

===Material source===
The quantity of construction materials used in facilities can be reduced through avoiding material use, using materials more intelligently and using materials for more than one use.

#Avoided material use: Have materials been avoided where these are not required? For instance, can ceilings and plastering be avoided through better concrete finishes? Can improved floor finishes be used to avoid the requirement for carpets and tiling? Can the use of passive systems reduce the requirement for ducting and plant?
#Intelligent material use: Can quantities of materials be reduced through different designs and specifications? For instance, can structural strategies such as pre-tensioning concrete slabs and waffle slabs be used to reduce concrete requirements? Can material use and wastage be reduced through use of precast elements?
#Dual plus use: Can materials be used for more than one purpose? For instance, can photovoltaic panels be used as a roofing material as well as to generate material?

===Sustainable sources===
Materials can be defined in terms of whether they are from sustainable or non-sustainable sources. Materials from sustainable sources include timber, cork, wool that are grown and therefore can be harvested on an on-going materials. Other materials such as plastics and metals are mined and therefore once these sources are depleted will not be available.

#Where possible, have materials from sustainable sources been specified? For example, have timber, and plant-based products been used in preference to materials that have to be mined and processed?
#Are materials from sustainable sources actually being grown and harvested on a sustainable on-going basis? For instance, has timber specified been certified by the Forest Stewardship Council (FSC) as being from a sustainable source? It is important to note that there are still timber products available, in particular hardwoods, that are harvested from tropical rainforests which are not being replanted and therefore are not considered sustainable sources.

===BIODIVERSITY===

===Objective===
The building supports biodiversity

===Introduction===
Biodiversity plays a very important role for man through providing ecosystem services. Ecosystem services include the production of food and water, the control of climate and disease, supporting nutrient cycles and crop pollination and spiritual and recreational benefits.

Ensuring that health facilities take into account biodiversity has a wide range of benefits including:

*Maintaining local ecosystem services
*Providing an natural amenity such as gardens which would could support recuperation.

===Biodiversity in health facilities===
Health facilities affect biodiversity through their location and in the way that site planning and landscaping is carried out. New facilities can minimise negative impacts on biodiversity by avoiding green field sites and building outside municipal boundaries. Biodiversity within health facility sites can be supported through considered site planning and landscaping strategies.

===Criteria===
Biodiversity in health facilities can be addressed in a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key biodiversity considerations have been addressed. These are outlined below.

===Site location===
Biodiversity is being lost at a rapid rate through urban sprawl. Preserving existing biodiversity can therefore be achieved by avoiding green field site and building only within urban boundaries.

#Has the health facility been planned for a brown field (already built-on) sites?
#Has the health facility been planned for a location within an urban boundary so that this does not take up land that supports agriculture and or biodiversity.

===Design for biodiversity===
Biodiversity can be supported through site layouts and landscaping that retains existing biodiversity and enhances this.

#Has planning of the health facility ensured that existing valuable biodiversity on site is preserved?
#Have valuable links and wildlife corridors between biodiversity on the health facility and adjacent sites been preserved?
#Has the landscaping strategy enhanced existing biodiversity? Does this include the introduction of appropriate loc

==TRANSPORT==

===Objective===
The building supports energy efficient transportation

===Introduction===
Ensuring that health facilities support energy efficient transportation has a wide range of benefits including:

*Reduced air pollution and noise from vehicles
*Health benefits from increased opportunities for exercise
*More affordable transport for health facility users
*Reduced space requirements as a result of reduced parking and road requirements.

===Transportation in health facilities===
Transportation is important in health facilities as large numbers of people and goods need access to these facilities everyday. This includes health facilities staff who commute and health facilities users. The right location and provision of facilities help ensure that the transport impacts associated with this access is minimized and potential health benefits such as exercise are supported.

===Criteria===
The transportation in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that transportation considerations have been addressed. These are outlined below.

===Access to public transport===
Locating health facilities near public transport facilities and enabling good access to these encourage people to use these in preference to personal vehicles. The use of public transport can be encouraged by ensuring that health facilities are located near well used public transport nodes and that there are good walking routes between these and key locations within the health facility.

#Is the health facilities located near good public transport nodes such as minibuses, buses, trains and bus rapid transport systems?
#Are there safe, direct and easy-to-use routes between public transport nodes and key locations within the health facility? (see also provision for walking criteria)

===Provision for walking===
Making provision that encourages walking helps to ensure that people walk to health facilities instead of using vehicles. Walking can be encouraged through safe, direct and easy-to-use routes.

#Are there safe direct pedestrian routes to and around the health facilities site from neighboring areas and public transport nodes? (see also criteria 4 for detail)
#Are there safe direct pedestrian routes from neighboring areas to key locations within the health facility such as the main reception? (see also criteria 4 for detail)
#Are there safe direct pedestrian routes within the health facilities between all locations within the health facility? (see also criteria 4 for detail)
#Does pedestrian provision include safe road crossings such as bridges, underpasses and zebra crossings? Are routes wide enough and have appropriate finishes and other required characteristics to enable them to be easily used by people with disabilities and by predicted pedestrian numbers? Are routes safe and benefit from visual supervision by surrounding facilities and other pedestrians? Have lighting and appropriate security safety mechanisms been put in place if routes will be used at night?

===Provision for cycling===
Making provision that encourages cycling helps to ensure that people cycle to health facilities instead of using motorized vehicles. Cycling can be encouraged by providing secure cycle storage, changing or showering facilities and safe, easy-to-use local routes.

#Are there safe direct cycle routes to and around the health facilities site from neighboring areas? (see also criteria 4 for detail)
#Are there safe direct cycle routes from neighboring areas to key locations within the health facility such as the main reception? (see also criteria 4 below for detail)
#Are there safe direct cycle routes within the health facilities between all locations within the health facility? (see also criteria 4 for detail)
#Does this cycle provision include designated, separate routes and safe road crossings and junctions? Are routes wide enough and have appropriate finishes and other required characteristics to enable them to be easily used by predicted numbers of cyclists? Are routes safe and benefit from visual supervision by surrounding facilities and other cyclists? Have lighting and appropriate security safety mechanisms been put in place if routes will be used at night?

==RESOURCE USE==

===Objective===
The building makes efficient use of resources

===Introduction===
There are limited resources in the form of land, finance and raw materials to construct and maintain facilities. It is therefore important to use these resourced carefully. Benefits associated with careful resource use include:

*Avoiding waste
*Ensuring effective and efficient use of resources
*Ensuring that resources are available for other uses where these are not required

===Resource use in health facilities===
Health facilities use financial resources to enable construction and maintenance. They also consume materials and energy in their construction. Finally health facilities use land. Careful use of these resources enables waste to be avoided and these resources to be available for other uses where this is required.

===Criteria===
Resource in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that key resource considerations have been addressed. These are outlined below.

===Site density===
Detailed long term strategic plans for health facilities should be developed that take into account future projections. These should ensure that expansion or changes that are envisaged can be accommodated. However care should be taken that unnecessarily large areas are allocated for health facilities to avoid land being unused.

#Has a long term strategic site plan been developed for the health facility that addresses changes that may occur in the future, such as expansion or contraction?
#Has the over allocation of space for health facility sites been avoided?

===Occupancy density===
Robust sustainable facilities accommodate change through flexible and adaptable allocation and configuration of space. While this is important over provision of space should be avoided as this space will need to be serviced and maintained even if it is not used. Health facilities should therefore be designed to support spatial efficiency and effective use.

#Is the overall space allowance in the health facility in line or below health facilities norms, for instance, in terms of gross area per bed?
#Are the proportions of spaces use in the health facility in line with good practice health facilities design? For instance is the space allocated for circulation, support and ancillary services as a proportion of the total area in line with best practice norms?

===Food production===
Food production in the form of orchards or vegetable gardens are a productive way of using land that leads to both environmental and health benefits. Where land is available in health facility sites and there is water and appropriate capacity, food production should be encouraged and produce made available to be consumed within the health facility or by local communities.

#Has available land within the health facility site been developed for local food production?
#Has appropriate provision in the form of irrigation, fencing, organizational and capacity requirements been made to ensure that food production will be effective and sustained?

==MANAGEMENT==

===Objective===
The building is managed to support sustainability

===Introduction===
Facilities can be designed to support effective management. Systems can also be developed to ensure that facilities are effectively and efficiently used and maintained. In health facilities this is particularly important because of the stringent environmental requirements for health care and the high operating costs of the facility.

Ensuring that health facilities are effectively managed has a wide range of benefits including:

*Ensuring that operating costs are controlled and reduced
*Minimising disruption to health care as result of maintained and repairs
*Ensuring that maintenance is planned for and effective carried out

===Building management in health facilities===
Building management aims to ensure that health facilities are effectively operated and maintained in order to support healthcare services that they accommodate. Personnel with appropriate capacity, mandate and resources should be allocated to this function.

===Criteria===
Building management in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that building management considerations have been addressed. These are outlined below.

===Energy and water sub metering===
Energy and water sub metering enables the manager of a health facility to manage the consumption of energy and water and reduce costs associated with these services.

#Has energy sub metering been installed which enables energy consumption in all areas with substantial loads to be measured and monitored? Do energy meters support assessment of energy consumption trends, profiles and comparison with benchmarks?
#Has water sub metering been installed which enables water consumption in all areas with substantial consumption to be measured and monitored? Do water meters support assessment of water consumption trends, profiles and comparison with benchmarks?
#Is water and energy consumption monitored and reported to senior management on a regular basis?

===Facilities management manual===
A facilities management manual provides technical detail on all aspects of the building and how they should be maintained and managed. It is useful because it provides a repository of knowledge and information that can be used by facilities managers and their staff to ensure that health facilities are effectively managed and maintained.

#Has a detailed facilities management manual been developed for the health facilities? Does this include a detailed schedule for maintenance and other checks on equipment such as lighting, pluming fittings and HVAC
#Does the facilities management manual refer to a full set of as-built drawings and equipment manuals? Have a full set of hard copy and electronic copy as-built drawings and manuals been provided?
#Have facilities managers in the building had a full induction on the building’s systems and the facilities management manual?
#Does the facilities management manual get regularly reviewed and updated to reflect upgrade and renovations details.

===Senior management commitment===
Effective management of facilities can be supported by senior management commitment. Regular reporting on facilities performance such as energy and water consumption serve to ensure that management is aware of these issues and are likely to ensure that the appropriate mandate and resources are in place to improve this.

#Have facilities management policies in relation to sustainability been developed? For instance, are there policies or guidance on how energy and water consumption will monitored and managed?
#Have facilities management policies or guidelines been endorsed by senior management? Is there are requirement for facilities management to report on facilities performance on a regular basis to senior management?

==LOCAL ECONOMY==

===Objective===
The building supports the local economy

===Introduction===
The construction and maintenance health facilities are a significant investment by government. This investment, if considered carefully, can be used to support the local economy and employment. This is done by specifying local products and services from the local area.

Ensuring that health facilities support the local economy has a wide range of benefits including:

*Increased local employment
*Increased local capacity for new construction and maintenance of facilities

===Local economy in health facilities===
Supporting the local economy can be achieved in new facilities by understanding the nature and type of local building product suppliers and where appropriate specifying these in the building. Similarly understanding the capacity and skills of local contractors can be used to ensure that these are developed and enhanced by being engaged in the construction and maintenance of health facilities.

===Criteria===
Supporting the local economy in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key waste considerations have been addressed. These are outlined below.

===Small enterprise support===
The waste and emissions in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key waste considerations have been addressed. These are outlined below.

Minimizing irrigation water requirements can be used to reduce water consumption. The following measures can be considered:

#Are small enterprises provided with opportunities to tender for relevant construction and maintenance contracts? Can local, small enterprises be given preference in the awarding of work?
#Where local small enterprises have limited capacity and experience, can they be supported by encouraging partnerships with more established and larger enterprises?

===Material and component procurement===
The specification of local materials and components in the construction of health facilities can provide a significant incentive to local suppliers and manufacturer to develop appropriate products and capacity. This in turn provides local employment and can ensure that maintenance and repairs at the facilities can be carried out more quickly and cost effectively.

#Has a review of local materials and components been carried out?
#Have local materials and components been specified?

===Construction employment===
The construction industry can employ significant numbers of people. This can be supported through designs, specifications and labour intensive construction techniques which can be used to construct facilities without significant cost or time implications. Local construction employment improves the local economic impact of projects and ensures that there is local capacity to undertake repairs and maintenance of facilities.

#Is construction employment a key consideration in the design, specification and construction of the facility?
#Have opportunities to create local employment been sought and developed through the project?

==PRODUCTS AND SERVICES==

===Objective===
The building supports use of more sustainable products and services

===Introduction===
Products and services used in health facilities have a range of impacts and planning can be used to maximise beneficial impacts and avoid negative impacts. The construction and maintenance health facilities are a significant investment by government. This investment, if considered carefully, can be used to support the local economy and employment. This is done by specifying local products and services from the local area.

Ensuring that health facilities support the more sustainable products and services has a wide range of benefits including:

*Reduced waste
*Increased support for sustainable choices and options for health facility users

===Products and services in health facilities===
Supporting the local economy can be achieved in new facilities by understanding the nature and type of local building product suppliers and where appropriate specifying these in the building. Similarly understanding the capacity and skills of local contractors can be used to ensure that these are developed and enhanced by being engaged in the construction and maintenance of health facilities.

===Criteria===
Supporting the more sustainable products and services in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key product and service considerations have been addressed. These are outlined below.

===Local produce===
Impacts associated with transport and storage / refrigeration mean that produce imported from some distance away generally has significantly higher ecological footprints than local produce. Health facilities can therefore reduce ecological footprints associated with food through using local produce as far as possible.

#Is local produce used in preference to produce imported some distance away?
#Has the use of local produce been made a requirement in outsourced catering contracts?

===Vegetarian options===
Meat-based meals generally have significantly higher ecological food print requirements relative to vegetarian meals. Providing vegetarian options can therefore support reduced food impacts within health facilities.

#Are vegetarian options provided in catering establishments within the health facility?
#Has the provision of vegetarian options been made a requirement for outsourced catering contracts?

===Drinking water===
Waste streams can be reduced by providing alternatives to bottled drinking water. Drinking water can be provided through strategically located drinking fountains, as well as being supplied in reusable containers. A ready supply of drinking water also has health benefits.

#Is non-bottled drinking water readily and freely available throughout the health facility?

===Reuseable vessels===
Significant waste streams can be avoided through the use of reusable vessels. In particular disposable food and drink vessels can be avoided by providing reusable vessels. This option can be supported through provision of required storage and washing and facilities.

#Have reusable vessels been specified in preference to disposable containers, for services such as catering?
#Has adequate provision been made for reusable vessels in the form of storage and washing facilities?

==ACCESS==

===Objective===
The building supports access to facilities

===Introduction===
Current work patterns and lifestyles mean that many people have to access facilities such as banking, retail, childcare and communications on a regular basis. Ensuring that these facilities are within the health facility or within easy walking distance helps to avoid or reduce associated time and transport impacts.

Ensuring that health facilities support access to facilities has a wide range of benefits including:

*Reduced transport impacts
*Reduced time spent travelling to and from facilities

===Access to facilities in health facilities===
Supporting access to local facilities can be achieved through incorporating these into the health facility. Alternatively the health facility can be located near where these exist. It may also be possible to work with relevant service providers in order to provide these locally.

===Criteria===
Supporting access to facilities in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key access considerations have been addressed. These are outlined below.

===Banking===
Access to banking can be provided through formal banking facilities or through bank ATMs. This can be provided within the health facility or within easy walking distance of this.

#Are banking facilities available within the health facilities or within the local area?

===Grocery retail===
Grocery retail can be provided through local shops, supermarkets and markets. This can be provided within the health facility or within easy walking distance of this.

#Are grocery retail facilities available within the health facility or within the local area?

===Communication===
Access to telephone and internet can be provided through internet cafes or at stand alone kiosks. This can be provided within the health facility or within easy walking distance of this.

#Are internet and telephone facilities available within the health facility or in the local area?

===Café===
Access to catering facilities can be provided through cafes, restaurants or canteens. Refreshments should be affordable and accessible to both staff and health facility users. This can be provided within the health facility or within easy walking distance of this.
1. Is there an accessible, affordable café, restaurant or canteen within the health facility or in the local area?

===Childcare===
Significant waste streams can be avoided through the use of reusable vessels. In particular disposable food and drink vessels can be avoided by providing reusable vessels. This option can be supported through provision of required storage and washing and facilities.

#Is there a childcare facility within the health facility or in the local area?

==HEALTH==

===Objective===
The building supports a healthy and productive environment

===Introduction===
Health facilities by their definition aim to support health and well being in their users. In addition to medical care health can be promoted through beneficial environmental conditions including a plentiful supply of fresh air, views and optimum thermal comfort conditions. It is particularly important to avoid conditions and situations that may be harmful to human health.
Ensuring that health facilities support the health in facility users and construction workers services has a wide range of benefits including:

*Improved recovery rates for patients
*Reduced absenteeism associated with environmental conditions by health facility staff
*Reduce injury and absenteeism rates associated with dangerous or harmful working construction environments

===Criteria===
Ensuring construction and health facilities promote health can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that health promotion considerations have been addressed. These are outlined below.

===External views===
Views and a connection to the external environment improve internal environmental conditions and can help improve recovery rates and reduce employee absenteeism.

#Do health facility staff working areas have views to the external environment
#Do patient areas have views of the external environment?

===Daylight===
Day lighting can help reduce energy consumption associated with artificial lighting. It also improves internal environmental conditions for patients and health facility employees.

#Are health facility staff working areas well day lit?
#Are patient areas well day lit?

===Ventilation===
High levels of fresh air are important for human health and productivity. This can be provided through natural or mechanical ventilation. Where mechanical ventilation is used sufficiently high levels of external, fresh air should be provided and recirculated air should be avoided or minimized.

#If the condition of outside air makes it unfit for direct ventilation use, is it appropriately pre-treated and filtered by the ventilation system?
#Are health facility staff working areas well supplied with good quality outside air?
#Are patient areas well supplied with good quality outside air?

===Building materials===
Building materials can have negative impacts for human health associated with their extraction and manufacture. They may affect health in facilities, through for instance offgassing hazardous chemicals. Construction materials should therefore be screened to avoid products being used in health facilities that have negative impacts on human health.

#Has criteria been developed and applied for the selection and screening of building materials?
#Have all building materials that may off gas substances such as formaldehyde and volatiles organic components that may be harmful to human health been avoided?

===Contractor health and safety===
There are considerable health and safety risks in the construction industry. Considering health and safety in the design of health facilities can be used to reduce health and safety risks associated with construction and maintenance. Making provision for safe access to glass facades or to high level lighting helps to ensure that this can be installed, cleaned and maintained without undue health and safety risks. In addition, addressing health and safety comprehensively in contract and construction planning, procedures and processes can be used to eliminate many construction health and safety risks.

#Has contractor health and safety been considered as a key issue in the design of the building? Have construction risks been minimised through appropriate design risk assessments and mitigation?
#Have detailed construction plans, procedures and processes been developed to minimise risks where these may occur during construction?
#Has appropriate health and safety procedures been put in place to ensure that plans are implemented and monitored?

==EDUCATION==

===Objective===
The building supports education

===Introduction===
Education and on-going learning is increasingly been seen as an essential component of sustainable development and a competitive economy. This is recognised in health care through the requirement for health care professionals to under continued professional development (CPD). Education and on-going learning can be supported through technology and spaces within facilities that support this. Examples of this include training rooms and access to ICT and reading material. In addition well packaged
Ensuring that health facilities support the education has a wide range of benefits including:

*Improve ability by health facilities staff to keep up-to-date with new developments in health care
*Ability to attract and retain staff

===Criteria===
Ensuring construction and health facilities promote education and on-going learning can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that education and on-going learning considerations have been addressed. These are outlined below.

===Contractor education===
There are considerable health and safety risks in the construction industry. Considering health and safety in the design of health facilities can be used to reduce health and safety risks associated with construction and maintenance. Making provision for safe access to glass facades or to high level lighting helps to ensure that this can be installed, cleaned and maintained without undue health and safety risks. In addition, addressing health and safety comprehensively in contract and construction planning, procedures and processes can be used to eliminate many construction health and safety risks.

#Has contractor health and safety been considered as a key issue in the design of the building? Have construction risks been minimised through appropriate design risk assessments and mitigation?
#Have detailed construction plans, procedures and processes been developed to minimise risks where these may occur during construction?
#Has appropriate health and safety procedures been put in place to ensure that plans are implemented and monitored?

===Notice boards===
Notices are very easy and cost effective way of communicating information. They can be used to support education and awareness by drawing attention to new or important education. For instance, awareness and reminders about new health care policy, procedures and processes can be communicated. Notice boards have the benefit that they can be located where they will be seen by all personnel on a regular basis and are not reliant on a particular technology, such as email. This helps to ensure information can be communicated to all levels of staff within a health facility.

#Have notice boards been located in key locations in the health facility where they can be used to communicate key information to facility staff and users?
#Have communication and education plans been developed that will ensure that notice boards will be updated throughout the year with relevant notices and information?

===Space for learning===
Formal training can be supported through access to training rooms. More informal on-going learning can be provided through access to resource centres where learning material, computers and the internet can be accessed.

#Are there appropriately sized and equipped facilities to accommodate formal training?
#Are there appropriately sized and equipped facilities to support informal on-going learning by staff?

===Employee induction===
Employee induction refers to awareness training provided to new employees. This can be used to support sustainability by developing awareness in health facility staff about sustainable building systems and how they should be used. This may include aspects such as lighting and HVAC operation as well as recycling procedures.

*Have employee induction processes been developed?
*Do these include detailed information on systems in the building that aim to support sustainability?

===Building user manual===
Building user manuals aim to complement employee induction processes by providing easily accessible and understanding information related to a facility in order to support user behaviour that support sustainability.

#Has a building user manual been developed?
#Is this readily accessible and easy to use?

==INCLUSION==

===Objective===
The building is inclusive of diversity in population

===Introduction===
Design for inclusion helps to ensure that facilities can be used by all users including older people, sick people, people with children and people with disabilities. Inclusive design also often means that facilities are safer and easier to use. In health facilities both of these aspects are particularly important.

Ensuring that health facilities are inclusive has a wide range of benefits including:

*Less requirement to replicate facilities
*Facilities that are easier and safer to use

===Criteria===
Ensuring health facilities are inclusive can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key inclusion considerations have been addressed. These are outlined below.

===Accessible transport===
Inclusive access to health facilities is an important consideration. This means ensuring that people who may be ill, infirm, old or have disabilities are able to access health facilities easily. This requires accessible routes from places for work and accommodation to the facilities and often requires easily accessible local public transport systems. This can be p

Ensuring that health facilities support the education has a wide range of benefits including:

#Are there regular, affordable and efficient local transport systems?
#Can these be accessed readily from health facility users’ accommodation and places of work?
#Can the health facility be accessed readily from public transport?
#Is public transport provision inclusive?

===Environmental access===
Facility design and management for environmental access can be used to ensure that health facilities are inclusive. This requires a comprehensive approach that ensures that access consideration are effectively integrated into all aspects of health facility design. Guidance on this aspect is provided in the IUSS d

#Does the facility design fully comply with the IUSS environmental access requirements?
#Are systems and management in place to ensure that environmental access standards are maintained during operation?

===Access to affordable accommodation===
There is an increasing shortage of affordable accommodation in many South African cities. This can have a range of negative impacts including the requirement for long distance commuting, disrupted family life, and reduced family budgets for non-transport related costs such as education and health. Increasing local affordable accommodation can be achieved through partnership agreements with local developers and social housing organizations.

#Is there affordable local accommodation for health facility staff?
#If this does not exist, have initiative been taken to develop this with developers and or social housing institutions?

==SOCIAL COHESION==

===Objective===
The building supports social cohesion

===Introduction===
Social cohesion refers to the extent to which individuals within a community understand, collaborate, trust and work together. It is valuable because it enables collective knowledge and resources to be used more effectively and efficiently to support common goals. Within a health facility improved social cohesion can support improved healthcare with fewer resources by sharing and using these more effectively. It can also support improved communication and cooperation within health teams and therefore improving levels of service and reducing wastage and mistakes.

Ensuring that health facilities support social cohesion has a wide range of benefits including:

*More efficient and effective use of resources
*Improved communication and coordination
*Reduced wastage

===Criteria===
Ensuring health facilities support social cohesion can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key social cohesion considerations have been addressed. These are outlined below.

===Shared used of facilities===
Shared use of facilities helps to ensure that valuable facilities are well used and beneficial impacts are experienced across a wider range of people. Capital and operating costs of the facility may also be reduced as these are shared between a larger number of organizations or individuals. This concept can be applied to health facilities in a range of different ways. For instance, sharing arrangements with a local sport club or fitness center can be used to enable a health facility to use swimming pools and other facilities for rehabilitation without having the ongoing costs and management of this facility.

#Have shared use, and possibly development, of facilities been explored with local organizations?
#Have appropriate design considerations been put in place to ensure effective shared use of facilities?
#Have appropriate management considerations been put in place to ensure effective shared use of facilities?

===Social spaces===
Social spaces, such as canteens, cafes and common rooms can play an important role in the life of organization. They not only provide a respite from work environments they also provide a space for relaxed social interaction. This interaction and the relationships and communication networks created can may a significant impact in improving organizational effectiveness and responsiveness. In health care facilities this is a valuable resource which helps to motivate individuals and build strong teams that are able to provide effective and responsive health care.

#Have an appropriate number and type of social spaces been provided within the health facility?
#Will these facilities support easy social interaction within and between health teams, as well as cross health facility staff structures?

===Stakeholder involvement===
Involving people in decisions on issues will have an impact on them is a useful way of helping ensure that there is support for an initiative or a process. Structured involvement of stakeholder helps to ensure a shared understanding can be developed, joint decisions made and there is efficient and effective implementation. For instance, within a health facility, effective involvement of key stakeholders can help goals such as improved energy efficiency through ensuring that managers, building technical staff and health services staff understand the goal, the means that this will be achieved and can see their role in supporting this.

#Has there been appropriate stakeholder involvement in the design of health facilities?
#Has there been appropriate stakeholder involvement in the management of health facilities?

==REFERENCES==

#[http://www.cidb.org.za/publications/Documents/Greenhouse%20Gas%20Emission%20Baselines%20and%20%20Reduction%20Potentials%20from%20Buildings%20in%20South%20Africa.pdf CIDB, 2009. South African Report on Greenhouse Gas Emission Reduction, Potentials from Facilities, A Discussion Document. Construction Industry Development Board. Page 22].
#. DEAT, 1995. Urban Open Space: Guidelines for effective management. Discussion document based on Agenda 21 and the RDP
#DEAT, 1998. National Environmental Management Act. Department of Environment and Tourism, Pretoria. Chapter 1.
#DEAT 2009, State of the Environment Report Accessible from http://soer.deat.gov.za/themes.aspx?m=387
#DEAT, 2009a, The National Climate Change Response Policy. Department of Environment and Tourism, Pretoria. Page 8.
#DEAT, 2009b, The National Climate Change Response Policy. Department of Environment and Tourism, Pretoria. Page 14
#DEAT, 2009c, The National Climate Change Response Policy. Policy Department of Environment and Tourism, Pretoria. Page 20.
#EMM and GDACE, 2007. Environmental Management Framework for Ekurhuleni. Ekurhuleni Metropolitan Municipality and Gauteng Department of Agriculture, Conservation and the Environment
#Hewitson, B. Engelbrecht, F Tadross, M. and Jack, C., 2005. General conclusions on development of plausible climate change scenarios for southern Africa, in: R. E. Schulze (ed.), Climate Change and Water Resources in Southern Africa: Studies on Scenarios, Impacts, Vulnerabilities and Adaptation, Water Research Commission, WRC Report 1430/1/05, Pretoria, South Africa.
#IPCC, 2007. Climate Change 2007, Synthesis Report. Inter Governmental Panel on Climate Change. 2007.Page 7
#SEA 2006, State of Energy in South African Cities. Sustainable Energy Africa. Cape Town.
#South African Bureau of Standards. 2007. SANS 204 Energy Efficiency in Facilities
#WWF 2006. Living Planet Report 2006.World Wildlife Fund. Accessed from www.panda.org.

==APPENDIX A: SUSTAINABILITY INTEGRATION PLANS==
 
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!Strategy
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!Monitoring
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[[Category:Crosscutting Issues]]

Legionella Control

2020-11-16T08:53:56Z

Tmojanaga: /* PONTIAC FEVER */

{{Stub}}
{{Anchor|Section1}}
==Section 1==

==1.1 HISTORY==
Legionnaires’ disease was first described after a pneumonia outbreak at an American Legion Convention held in Philadelphia during 1976. In total, 182 delegates were affected and 29 died before workers at the Centers for Disease Control and Prevention (CDC) based in Atlanta, USA isolated the causative organism in January 1977. The organism was placed in the family Legionellaceae, genus Legionella to commemorate the first victims of the disease. The first species was named Legionella pneumophila (Greek for “lung loving”).

Figure 1.1 The first Legionnaires’disease outbreak

It soon became clear that legionellae were not really new; retrospective studies showed that an organism isolated for the first time in 1944 (called Tatlockia micdadei) actually belonged to the genus Legionella. The first strain of Lpneumophila was isolated already in 1947 from a guinea pig that had previously been inoculated with blood from a patient with what was called an “unknown febrile disease” at the time.

The two decades following the discovery of the family Legionellaceae was marked by rapid developments in Legionella detection and the identification of numerous new species. Twenty-eight new Legionella species and two “Legionella-like amoebal pathogens” (LLAPs) (LLAP-1 and LLAP-6) were isolated during the 1980s, mostly from sources in the USA. The 1990s were marked by an increase in Legionella isolation from countries in Europe and Australia with fifteen new Legionella species being described for the first time.

Figure 1.2 Intracellular Legionella organisms

More than half of the currently known Legionella species are potentially pathogenic to humans. L. pneumophila is still implicated in >80% of infections; however, as more species are isolated from environmental sources worldwide, even those species not yet associated with disease should be considered as potentially pathogenic until proven otherwise. For example, L. longbeacheae, often isolated from potting soil, is considered the most common cause of legionellosis in Australia.

Legionellae are faintly staining gram negative, rod-shaped, non acid fast bacteria that to not form spores or capsules. All species except L. oakridgensis are motile. Legionellae are typically between 0.3 and 0.9 µm wide and 1- 20 µm long. However, shorter forms measuring 1- 2 µm in length are often observed in clinical specimens or under conditions of iron deprivation.

Figure 1.3Gimenez stain: Legionella bacteria

The ability of legionellae to grow in water is influenced by several factors. They can grow at temperatures between 20°C and 60°C, with optimal growth occurring between 37°C and 45°C. They prefer a pH in the range of 5.0 9.5 and only grow in the presence of Lcysteine, HCl and iron salts. Legionella-like amoebal pathogens (LLAPs) are very similar to Legionella species in that they are gram negative, infect amoebae and can survive and multiply intracellularly. However, they cannot be cultured on laboratory media. The first LLAP was isolated 1 from soil in Poland in 1954 and was named Sarcobium lyticum. The next isolation of an LLAP was in England more than 20 years later. Since then, LLAPs have been isolated from various sources, mostly associated with confirmed cases or outbreaks of 2 3 Legionnaires’ disease. Three of the LLAPs have since been reclassified as L. drozanskii, L. rowbothamii and L falloni. The currently known LLAPs are listed in Table 1.2.

===1.2 INTERACTIONS WITH PROTOZOA===
Legionellae are slow-growing organisms that require a combination of nutrients for growth. Due to their fastidious nature and lack of antibiotic activity, they may be replaced by faster growing organisms if they do not have an alternative means of survival in aquatic environments. The fact that legionellae are ubiquitous in these environments suggests that protozoa, especially amoebae, play a supportive role in their survival and multiplication. In fact, their natural habitat, parasitic to protist hosts, has now been 4 proven.

Table 1.1 Legionella species ORGANISM SGs YEAR SOURCE PATHOGEN L adelaidensis L anisa L beliardensis L birminghamensis L bozemanii L brunensis L cherrii L cincinnatiensis L donaldsonii* L drozanskii (LLAP-1) L dumoffii L erythra L fairfieldensis L fallonii (LLAP-10) L feeleii L geestiana L gormanii L gratiana L gresilensis L hackeliae L israelensis L jamestowniensis L jordanis L lansingensis L londiniensis L longbeacheae L lytica L maceachernii L micdadei L moravica L nautarum L oakridgensis L parisiensis L pittsburghensis L pneumophila L quateirensis L quinlivanii L rowbothamii (LLAP-6) L rubrilucens L sainthelensi L santicrucis L shakespeari L spiritensis L steigerwaltii L taurinensis L tusconensis L wadsworthii L waltersii L worsleiensis 1 1 1 1 2 1 1 1 * 1 1 2 1 1 2 1 1 1 1 2 1 1 1 1 1 2 1 1 1 1 1 1 1 1 15 1 2 1 1 2 1 1 1 1 1 1 1 1 1 1991 1985 2001 1987 1980 1989 1985 1988 2002 2001 1980 1985 1991 2001 1993 1980 1991 2002 1985 1985 1985 1982 1994 1993 1982 1996 1985 1980 1989 1993 1983 1985 1980 1979 1993 1990 2001 1985 1984 1985 1992 1985 1985 1999 1990 1983 1996 1993 1993 Cooling water (Adelaide Australia) Faucet (Chicago), tap water (LA) Water, France Lung biopsy (Alabama) Lung aspirate (Toronto) Cooling tower water (Czechoslovakia) Thermally altered water (Minnesota) Lung tissue (Cincinnatti) * Tank of well water (Leeds 1981) Lung tissue Cooling tower water (Seattle) Cooling tower water (Fairfield Australia) Ship air conditioner (1994) Grinding machine coolant fluid Hot water tap, office building (London) Bronchial wash of pneumonia patient Thermal spa water (France) Water, France Bronchial biopsy (Ann Arbour) Water (Israel) Wet soil (New York) Water and sewage (Israel) Bronchial washing, hloramin patient Office building cooling tower (London) Human lung (Longbeach Australia) Previously Sarcobium lyticum Water (Phoenix) Human blood via yolk sac Cooling tower water (Czechoslovakia) Hot water tap (London) Cooling tower water (Pennsylvania) Cooling tower water (Paris) Synonym for L micdadei, strain TATLOCK Water (Pennsylvania) Shower in hotel bathroom (Portugal) Water in bus airconditioner (Australia) Water and sludge, industrial liquefier Tap water (Los Angeles) Spring water (Washington) Tap water (Virgin Islands) Cooling tower water (England) Lake water (Washington) Tap water (Virgin Islands) Water, hospital humidifier (Italy) Pleural fluid, transplant patient (Arizona) Sputum Potable water system (Australia) Industrial cooling water (England) Unknown Yes Unknown Yes Yes No Yes Yes * Yes Yes No Unknown Yes Yes Unknown Yes No Unknown Yes No No Yes Yes Unknown Yes Yes Yes Yes No Unknown Yes Yes Yes Yes Unknown No Yes Yes Yes No Unknown No No Unknown Yes Yes Unknown Unknown Sources: American Type Culture Collection; National Type Culture Collection. 2 Table 1.2 Legionella-like amoebal pathogens (LLAPs STRAIN HOSTS YEAR ORIGINAL SOURCE PATHOGENIC Sarcobium lyticum A polyphaga H vermiformis 1954 Soil Yes LLAP-1 A polyphaga 1981 Tank of portable water well Yes LLAP-2 A polyphaga H vermiformis 1986 Garage steam cleaning pit Yes LLAP-3 A polyphaga 1986 Sputum from pneumonia patient Yes LLAP-4 A polyphaga 1986 Hospital whirlpool bath Yes LLAP-5 A polyphaga 1988 Nursing home plant spray Yes LLAP-6 A polyphaga H vermiformis 1988 Factory liquefier tower Yes LLAP-7 A polyphaga H vermiformis 1991 Hotel whirlpool spa Yes LLAP-8 H vermiformis 1990 Hospital shower Yes LLAP-9 A polyphaga H vermiformis 1992 Factory cooling tower Yes LLAP-10 A polyphaga 1994 Ship air-conditioning system Yes LLAP-11 A polyphaga 1993 Furnace cooling system Yes LLAP-12 A polyphaga 1994 Furnace cooling system Yes 3 Adapted from Adeleke 1996 5

Rowbotham was the first to demonstrate interactions between legionellae and protozoa. To date, protozoa of the genera Acanthamoeba, Tetrahymena, Naegleria, Echinamoeba and Vanella species have been implicated in these interactions. Not much is known about the metabolic and physiological status of legionellae after passage through protozoa, but in vitro studies have shown changes in their physiological status resulting in iron deprivation, possibly changing the susceptibility of the released bacteria to chemical inactivation. Although they can survive extracellularly, this phase is believed to be only temporary while they are searching for new hosts to 6 infect. Furthermore, it was recently documented that very few Legionella bacteria are needed to start intracellular replication. Some workers have reported a 7000 times increase in Legionella colony forming units (CFU) after intracellular replication buth there is no consensus yet as many believe that this intracellular replication cycle is not necessary for the proliferation of legionellae within mixed bacterial populations. From these studies it is clear that there is still extensive research to be done on this aspect of Legionella survival in the environment. Until more becomes known, it is unsafe to assume that the absence of protozoa within water samples prevents the survival of legionellae; as long as there are other bacterial species present, appropriate measures should be taken to prevent Legionella proliferation.

===1.3 HOWDOES THE INTERACTION WITH PROTOZOABENEFITLEGIONELLAE?===
Amoeba trophozoites feed and multiply in water and biofilm. When conditions become unfavourable, these trophozoites are transformed into cysts with hard, impermeable outer walls that provide protection for ingested Legionella organisms. When conditions become more favourable, the cysts change to trophozoites again and the bacteria are set free. Legionellae have been 7 recovered from cysts treated with 50 parts per million (ppm) chlorine suggesting a high level of protection by the cysts. This high resistance of amoebal cysts to biocides may be the mechanism for the apparent reseeding of water systems by legionellae often experienced in the water treatment industry. However, recontamination may also occur via transmission of airborne cysts acting as carriers for the legionellae.

===1.4 HOWIMPORTANTIS LEGIONELLAIN SOUTH AFRICA?===
Very little has been published on Legionella in South Africa. After the initial introduction of diagnostic laboratory tests in 1979, legionellosis cases were identified in Durban, Port Elizabeth and Johannesburg during the early 1980's. By 1982, antibodies to L. 8,9 pneumophila had been demonstrated in 10% of hospitalised pneumonia patients, a figure that was confirmed in 1994. A high 9,10,11 prevalence of antibodies was also demonstrated in workers in the mining industry and the general public. Despite this high prevalence, only one Legionnaires' disease outbreak and less than 40 sporadic cases have been reported since legionellosis became notifiable in 1990. Similarly, very little is known about the prevalence of Legionella in the South African environment. Low concentrations of 12 legionellae were reported in 77% of cooling towers in a large study reported in 1991. More recently, culturable legionellae were present in 82% of industrial water samples tested; 54% of these samples yielded legionellae in numbers equal to or in excess of 1000 11 CFU/ml. 3

===1.5 LEGIONELLADETECTION===
Classical detection methods for Legionella species relied on the inoculation of susceptible guinea pig hosts. Although selective, these methods were expensive and time consuming and were soon replaced by isolation by culture on agar media. To improve the recovery of legionellae by culture, the use of certain selective media and steps were introduced to minimise contamination by nonlegionellae. In attempts to simplify Legionella identification, radioimmunoassays (RIAs), enzyme linked immunosorbent assays (ELISAs), agglutination tests and nucleic acid probes and polymerase chain reaction (PCR)-based assays have since been developed and tested.

Despite the relative success of these new methods for the detection of environmental legionellae, culture remains the method of choice. However, no single culture method has so far proven to be ideal for all samples in all given circumstances and environments. Even in the absence of contaminating bacteria or other inhibitory substances, the detection of small numbers of legionellae from environmental samples remains difficult. This, together with the lack of standardisation of methods, complicates the interpretation of culture results and comparisons of results from different laboratories. Variations in bacterial numbers in different areas within a water distribution system and the sampling method used often complicate the interpretation of culture results even further.

Previous studies have shown that the culture of Legionella species from environmental samples is complicated by the presence of 13,14 faster growing bacteria due to inhibition of legionellae on culture media in the presence of heterotrophic bacteria. For example, 15 Pseudomonas aeroginosa secrete bacterial substances into the surrounding media that dramatically inhibit Legionella growth. Although culture is still the gold standard, it remains time consuming and requires a certain level of technical skill. Legionellae may also enter a “viable but non-culturable (VBNC)” state under certain conditions which complicated culturing even further.)

Lp Lm L boz L dum L gor L long L jor L oak Growth on BCYE Growth on TSB Acid production Gelatin hydrolysis Urease Primary growth on FG Beta lactamase Hippurate hydrolysis Browning of tyrosine medium Blue fluorescence on CYE + - - + - + + + + - + - - + - - - - - - + - - + - - +/- - + + + - - + - - + - + + + - - + - - + - + + + - - + - - + or – - + - + - - + - - + - + - + - - - - nt +/- - + - Nt: not tested, +/- weak positiv; Lp L. pneumophila; Lm L. micdadei; Lboz L. bozemanii; Ldum L. dumoffii; Lgor L. gormanii; Llong L. longbeacheae; L jor L jordanis; L L. oakridgensis. oak Table 1.3 Selected characteristics of Legionella species Figure 1.4 Legionella colonies on agar (Sources: own laboratory pictures; Annual Report, American Water Technologies (2003) Recent developments in the molecular field opened doors for new detection assays of waterborne pathogens such as Legionella. These methods include: 16 ! DNA probe hybridisation; 4 ! ! ! ! ! ! !

====1.5.1 Polymerase chain reaction (PCR)====
Although the sensitivity of most of these techniques is insufficient for direct detection of legionellae in environmental samples, 18,19 PCR has proven to be a sensitive and rapid alternative to culture. Many PCR assays have been described, but relatively few of them have been extensively studied on clinical as well as environmental samples and none are routinely used.

====1.5.2 Immunofluorescence====
Immunofluorescence is a technique whereby antigen and antibody is bound to a fluorochrome (fluorescent stain) and then allowed to react with the corresponding antigen or antibody on a microscope slide. The results are viewed under a fluorescent microscope. There are many variations of immunofluorescent techniques but only direct immunofluorescence (DFA) and indirect immunofluorescence (IFA) is of importance in the confirmation of environmental legionellae. Direct immunofluorescence (DFA) is most commonly used for confirmation of Legionella species from environmental samples. The test is simple to perform, but interpretation requires a fair amount of experience, especially in highly contaminated samples. Antigen from the sample is fixed to a microscope slide using heat or acetone and covered with fluorescein-isothiocyanate (FITC) labelled globulin. Antigens in the sample bind to the labelled globulin and the resulting antigen-antibody complexes are visible under ultraviolet light. Direct immunofluorescence (DFA) is useful to detect antigens in clinical samples when cultures cannot be obtained, but its value for environmental samples is controversial. Nevertheless, it is used as a screening test by some laboratories. Cross-reactions that may lead to false positive results have been documented.

Figure 1.5 Legionella immunofluorescence/Fluorescent bacteria

17 Restriction enzyme digestion; 18,19 Polymerase chain reaction; 20 Soluble protein patterns; 21 DNA restriction endonuclease profiles; 22 Multilocus enzyme analysis; 23 Orthogonal-field-alteration gel electrophoresis; 24 Sodium dodecyl sulphate poly-acrylamide gel electrophoresis (SDS-PAGE).

====1.5.3 Fluorescent in situ hybridization====
Fluorescent in situ hybridization (FISH) is a technique whereby a fluorescent labeled DNA probe is used to detect a particular chromosome or gene that can then be visualised by fluorescence microscopy. FISH tests are useful for the detection of legionellae in respiratory tract samples but has not been extensively tested in environmental samples. The method makes use of oligonucleotide probes targeting rRNA and offers a fast and specific alternative to direct immunofluorsecence, culture and urine antigen testing in clinical laboratories. {{Expand}}

==Section 2==

==='''THE CHAIN OF INFECTION'''===
The mere presence of legionellae in a water distribution system does not necessarily imply a human health risk. For human infection to occur, certain conditions are necessary. These conditions are referred to as the “chain of infection” consisting of six links. All the links have to be present for disease to occur ([[#Legionella-Chain_of_Infection|Diagram: Chain of infection]] ). The first link, the pathogen, was discussed in [[#Section1|Section 1]].

{{Anchor|Legionella-Chain_of_Infection}}
[[File:Chain of infection.png|alt=Chain of infection|none|thumb|Chain of infection|450x450px]]

==='''SOURCES AND RESERVOIRS'''===
Legionellae are natural inhabitants of water, found a wide range of habitats. They are ubiquitous in streams, lakes and rivers. They also survive in dust, soil and mud. In fact, one of the species, ''Legionella longbeacheae'', is so often isolated from potting soil in Australia that soil has been suggested as the natural habitat of this particular species.

{{Anchor|Natural sources of Legionella}}
[[File:Natural sources of Legionella.png|alt=Natural sources of Legionella|none|thumb|Chain of infection|450x450px]]

Legionellae from these natural environments can be transmitted to man-made water systems by various means. For example, from raw water, during water treatment, as part of post-treatment after-growths within water distribution systems, during building and construction activities and during plumbing repair.

Once established, they can persist in the water supply for long periods of time and are difficult to eradicate. Therefore, their presence must be considered in all aspects of the design, operation and maintenance of buildings. For this to be effective, cooperation between engineers, occupational health practitioners and microbiologists is essential.

Figure 2.3 Man-made sources of Legionella

=====Water sources that provide optimal conditions for Legionella growth can be separated into those containing “non-potable” and those that contain “potable” water. '''Non-potable water distribution systems'''=====

Heat rejection devices like cooling towers, evaporative condensers and HVAC (heating, ventilation and air-conditioning) systems are often implicated as sources of legionellosis. They contain reservoirs filled with warm, recirculating water that makes them ideal for the growth, amplification and dissemination of micro organisms (including Legionella). In a typical water-cooled system air in induced through or blown over, packing material down which water, circulating from a pond under the packing, is allowed to fall by gravity, producing a large wetted surface that cools the falling water.

The constant fall of water through the tower, the large area of the basin, fill, pipes and heat exchanger, the warm temperature of the water, the high relative humidity and high organic content within these devices provide conditions that favour contamination by algae, protozoa, fungi and bacteria. The risk is increased further by the open nature of the systems, excessive aeration and the constant addition of fresh water to make up for water lost through evaporation.

In systems that are not regularly cleaned, sludge accumulates in the reservoir and slime adheres to water covered surfaces, resulting in the presence of large concentrations of micro-organisms, including legionellae, on these surfaces. In addition, water temperatures below 60°C, the age and configuration of the system, the pH of the water and the presence of certain metals may also increase the risk of contamination.

Water derived from municipal supplies but subsequently stored in cisterns, or conditioned prior to heating, is considered non-potable due to the deterioration in chemical and bacteriological quality during storage. Colonisation of such non-potable sources inside large buildings, such as hotels, factories or hospitals, may be a major cause of legionellosis.

====='''Potable (domestic) water distribution systems'''=====
Legionellae are often present in potable water supplies, especially in the hot water sections of these systems. The organisms may enter potable water supplies from the main source, even from municipal water, and survive standard treatment protocols because most municipal water systems are not routinely screened for the presence of legionellae and the organisms are chlorine tolerant. Once inside the system, they find a suitable environment to multiply and are usually very difficult to eradicate.

Legionella levels can rise from very low to very high within short periods of time. The factors that give rise to these fluctuations are not well understood and often very hard to determine. These factors include the age and configuration of the pipes, the degree of scaling and sediment and the potential for biofilm formation within the system increase the risk of contamination. Water temperatures of 25 – 42°C, stagnation and the presence of certain free-living amoebae capable of supporting the intracellular growth of legionellae are often mentioned as amplifying factors in published reports. The biofilm and scale that form on surfaces in water distribution systems provide nutrients for legionellae and protect them from hot water and disinfectants. Some materials used in these systems, for example neoprene washers, are more readily colonised than others (See [[Legionella Control#Materials used in the construction of potable water lines and fixtures|Table]]). Building location may also play a role in the colonisation of potable water with legionellae.

Hot water tanks are often colonised with legionellae, especially at the bottom where a warm zone may develop and scale and sediment accumulate. Hot water piping, especially dead-legs, presents an additional risk as legionellae thrive in stagnant water.

====='''Soil'''=====
Outdoors, the soil may be contaminated through contact with Legionella-polluted water and become a source of airborne bacteria during earth moving operations, such as construction work.
{| class="wikitable"
|+{{Anchor|Materials used in the construction of potable water lines and fixtures}}'''Materials used in the construction of potable water lines and fixtures'''
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'''Very good'''
|
Copper
|-
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'''Good'''
|

Neoprene

Other synthetic materials
|-
|
'''Reasonable'''
|
Steel
|-
|
'''Not recommended'''
|
Rubber

Plastics
|}

===='''Amplification'''====
Legionellae are usually present in low numbers in natural sources. However, certain factors present in man-made reservoirs can promote Legionella growth and amplification. To improve our understanding of Legionella, its potential to cause disease and how to better control the organisms in water systems, we must understand these conditions. The most important factors amplifying Legionella numbers in man-made reservoirs are listed in the table [[Legionella Control#Amplifying factors for Legionella in man-made sources and reservoirs.|Amplifying factors for Legionella in man-made sources and reservoirs.]]
'''Remember'''
Temperature data is usually based on laboratory studies and is not from actual system (piping) studies, which makes it even less reliable to use for Legionella control. System temperature on its own should therefore not be relied upon for Legionella control, because the so-called “system temperature” rarely indicates one uniform temperature throughout the entire system. Therefore, maintaining the system temperature does not guarantee Legionella control. Also, in plumbing systems, especially larger and/or more complex piping systems, legionellae have been shown to survive at even higher temperatures due to biofilm, dead-legs, and other complexities. It has been suggested that potable water systems be operated at temperatures as high as possible but take into account the risk of scalding injuries and energy conservation requirements.
{| class="wikitable"
|+{{Anchor|Amplifying factors for Legionella in man-made sources and reservoirs}}'''Amplifying factors for Legionella in man-made sources and reservoirs'''
|
'''TEMPERATURE'''
|

Legionellae can survive over a wide range of temperatures (20 – 60°C) with an optimum growth temperature of 37 – 45°C as illustrated in the figure [[Legionella Control#Natural sources of Legionella|Natural sources of Legionella]] 
|-
|
'''pH'''
|

Legionellae can survive and multiply at a pH of 5.0 – 8.5 
|-
|
'''STAGNATION'''
|

The presence of stagnant water in distribution systems increases the risk of Legionella contamination 
|-
|
'''WATER TREATMENT'''
|

The type of water treatment used may affect the numbers of legionellae present in a distribution system 
|-
|
'''DISINFECTANTS'''
|

The type, concentration and persistence of residual disinfectants in the system may affect the numbers and types of legionellae present 
|-
|
'''CHEMICAL PARAMETERS'''
|

The presence of organic carbon and certain metals like zinc and copper may influence the risk of Legionella contamination 
|-
|
'''RELATIVE HUMIDITY'''
|

Legionellae survive best at 65% relative humidity (RH) and are least stable below 55% RH
|-
|
'''SLIME, ALGAE AND PROTOZOA'''
|

Amoebae, cyanobacteria and flavobacteria have been associated with the growth of legionellae in water distribution systems
 
|-
|
'''CORROSION PRODUCTS'''
|

Legionellae numbers are usually highest in sections where corrosion products are present
 
|-
|
'''CONSTRUCTION'''
|

Major construction has been associated with outbreaks of legionellosis.

It is believed that legionellae are released from the soil during excavations from where they can enter the cooling tower of the building, air intakes or water pipes, or may be inhaled directly. Another possibility is that, during construction, nutrients already present in dust and dirt may become more readily available for the organisms. In new buildings, plumbing should be flushed before use. Renovated buildings may contain stagnant water, that should be flushed out before returning the building to normal use.
 
|-
|
'''WATER PRESSURE'''
|

An increase in water pressure may send dirt into a system, providing a food source for the bacteria or may dislodge scale and sediment containing legionellae from pipes.
 
|-
|
'''BIOFILM, SCALE AND SEDIMENT'''
|

In hot water systems the concentrations of legionellae are usually highest within biofilms and at the openings of water outlets. Biofilms are widespread in nature, and on most man-made surfaces when submerged in water.

Legionellae are not only able to survive in biofilms, but can proliferate and attach to susceptible hosts like protozoa, depending on the type of material on which the biofilm is formed. For example:

· Legionellae have been found in biofilms forming on plastic surfaces in water piping systems. At a temperature of 40° they were shown to account for approximately 50% of the total biofilm flora;

· Legionellae are less likely to be present on copper surfaces because copper generally do not support biofouling. If present, the bacteria are usually found in small numbers;

· Metal plumbing components and associated corrosion products provide iron and other metals needed for Legionella, thereby supporting their survival and growth.

Sediment and scale assists in the growth of supporting organisms and free-living protozoa, increasing the risk of contamination by legionellae. For this reason, its presence often indicates a possibility of Legionella contamination.

Algal slime also provides a stable habitat for their survival and multiplication.
 
|}
'''Disinfectants'''
After disinfection, municipal water supplies usually travel several kilometers before it reaches the point of use. During this course, disinfectant residuals diminish and there is increasing exposure to potentially biofilm-contaminated piping. Although municipal water systems are required to be disinfected at their points of distribution to conform to existing standards for bacterial disinfection, these standards are based upon the absence of coliform bacteria and do not include any specific testing requirements for Legionella.

====='''Transmission'''=====
After growth and amplification of legionellae to potentially infectious levels, the next requirement in the chain of infection is to achieve transmission of the bacteria to a susceptible host. Modern technology like cooling towers used to recirculate water for air-conditioning and humidifying purposes and other ventilation systems can cause the formation and distribution of aerosols through which the organisms can spread. Transmission can also occur through direct installation, aspiration or ingestion (Table [[Legionella Control#Dissemination of Legionella bacteria|Dissemination of Legionella bacteria]]).
{| class="wikitable"
|+'''Dissemination of Legionella bacteria'''
|
'''AEROSOLISATION'''
|

The most widely accepted theory for Legionella transmission is that the organism is aerosolised from a water distribution system and is inhaled as droplets of respirable size. Aerosolisation may affect persons outside as well as inside a building.
 
|-
|
'''DIRECT INSTALLATION'''
|

Respiratory therapy devices have the potential to disseminate legionellae by delivering gases at high temperatures and volumes, and by generating concentrated aerosols, enabling them to bypass the normal defence mechanisms of the respiratory system.
 
|-
|
'''INGESTION'''
|

The fact that diarrhoea is one of the symptoms of Legionnaires’ disease suggests the gastro-intestinal tract as the source in some cases. After infection via this route, the bacteria may spread to the respiratory tract, thereby causing Legionnaires’ disease.
 
|-
|
'''ASPIRATION'''
|

Another well documented mode of transmission that effectively gets bacteria into the lungs is aspiration (a “choking process” that often occur during drinking, swallowing or dlearing the throat, and during respiratory therapy). Evidence suggests that it may be a more common mode for Legionella dissemination than previously believed although it has not been widely described in the literature.<blockquote>

'''REMEMBER!'''

Never presume that you cannot get Legionnaires’ disease

from drinking water containing Legionella.</blockquote>

|}
[[File:Influence of temperature on Legionella growth (Freije 1996).png|alt=Influence of temperature on Legionella growth|none|thumb|604x604px|Influence of temperature on Legionella growth <ref name=":0" />]]

====='''INFECTION AND HOST SUSCEPTIBILITY'''=====
Infections caused by Legionella species are collectively known as ''legionellosis'' and include Legionnaires’ disease and Pontiac fever. Subclinical (asymptomatic) infections have been reported. Legionellosis occurs worldwide, in people of all ages and race groups, with no evidence of person-to-person spread of infection. It is most common in summer and autumn months. The incidence of legionellosis varies from country to country and from region to region. Recently, an increase in the worldwide incidence of reported legionellosis cases has become evident. This may be explained by the availability of improved diagnostic and testing methods, increased awareness of the symptoms and improved surveillance. However legionellosis, especially sporadic cases, is still not always reported to public health authorities, making it difficult to estimate its true incidence.

The mode of transmission, inoculum size, particle size and host susceptibility influence the severity of infection. Approximately half of the currently known Legionella species are implicated in disease, but ''pneumophila'' is still considered to be the causative agent in about 80% of diagnosed cases. However, this picture might change as the number of available diagnostic tests increases – it is thus important to regard all legionellae a potentially pathogenic until proven otherwise.

==Section 3==
===LEGIONELLA INFECTIONS===
Infections caused by Legionella species are collectively known as legionellosis and include Legionnaires’ disease and Pontiac fever.1,2 Subclinical infections have been reported. Legionella infections occur worldwide in people of all ages and race groups with no evidence of person-to-person spread of infection.3,4

===LEGIONNAIRES’ DISEASE===
Legionnaires’ disease (LD) is a severe multisystem disease with pneumonia as the most predominant clinical finding. Clinical features are similar to those of other pneumonias, making it difficult to diagnose.5,6 Symptoms range from a mild cough and slight fever to a coma with widespread pulmonary infiltrates and multisystem failure. Survivors usually recover completely although lung fibrosis and neurological abnormalities may persist in some cases. LD has a low attack rate but the mortality rate is high.

Legionnaires’ disease outbreaks occur frequently all over the world. In the United States, Legionnaires’ disease is considered to be fairly common and legionellae are among the top three causes of sporadic, community-acquired pneumonia. However, many cases are still not reported, as Legionnaires’ disease is difficult to distinguish from other forms of pneumonia. Although only approximately 1,000 cases are reported to the Centers for Disease Control and Prevention (CDC), it is estimated that over 25,000 cases occur every year, causing more than 4,000 deaths.

Despite this, only one outbreak has been reported in South Africa to date. However, previous South African studies indicated antibody levels to L pneumophila in 65% of healthy blood donors, 36% of healthy mineworkers, 10% of healthy factory workers and 16% of hospitalised pneumonia patients.7,8 One study reported seroconverion to L.

pneumophila in 9% of patients hospitalised between 1987 and 1988 with symptoms of community-acquired pneumonia.9

 
[[File:Hillside figure 3.1.jpg|thumb|420x420px|Figure 3.1 Legionella pathology|alt=|center]]

Figure 3.1 Legionella pathology
===RISK FACTORS===
In order for LD to occur, the host must be susceptible to infection. Older people (above 50 years of age) are more commonly infected. Men are more likely to be infected (ratio 3:1) but the racial distribution is usually consistent with that of the population involved.'''10'''

Table 3.1 lists the most common risk factors.
{| class="wikitable"
|+
!
!Table 3.1 Risk factors for development of Legionnaires’ disease
|-
|'''Patient demographics'''
|Smoking
Chronic pulmonary disease

Immunosuppression

Renal transplantation

Renal dialysis

Alcohol ingestion

Age > 50 years

Male
|-
|'''Environmental risks'''
|Exposure to construction activities
Exposure to air conditioning systems

Exposure to home air conditioning

Travelling and accommodation in hotels

Potable water

Hospitalization
|}
Source: Winn 1984 10

[[File:FIGURE 3.2 HISTOLOGY.jpg|center|thumb|500x500px|Figure 3.2 Risk Factors]]

===SYMPTOMS===
Legionnaires’ disease presents with a broad spectrum of symptoms, ranging from mild cough and low fever to stupor, respiratory and multi organ failure. Pneumonia is the predominant clinical finding. Early symptoms are mainly non-specific and include fever, malaise, myalgias, anorexia and headache.6,11 The temperature often exceeds 40°C and the patient may present with a slightly productive cough. Chest pain, occasionally pleuritic, can be prominent and when coupled with hemoptysis, may mistakenly suggest pulmonary emboli. Gastrointestinal symptoms (watery stools) are prominent, especially diarrhoea, which occurs in 20-40% of cases. Relative bradycardia has been over-emphasised as a diagnostic finding but is often seen in elderly patients with advanced pneumonia. Hyponatremia (serum sodium concentration ≥ 130 mmol/l) occurs more frequently in Legionnaires’ disease than in other pneumonias.

Extrapulmonary Legionnaires’ disease is rare but the clinical manifestations are often dramatic. These infections can easily be overlooked since the degree of suspicion is generally low in these cases. Legionella has been implicated in cases of sinusitis, cellulitis, pancreatitis, peritonitis and pyelonephritis. The most common extrapulmonary site of infection is the heart. There have been numerous reports of myocarditis, pericarditis, postcardiotomy syndrome and prosthetic valve endocarditis. In most cases there is no pneumonia symptoms present. Wound infections have also been reported.11

===INCUBATION PERIOD===
LD has an incubation period (the time it takes for symptoms to appear after exposure) of 2 – 10 days. The onset of symptoms may be sudden or gradual.

===DIAGNOSIS===
There are no reliable distinguishing clinical features to distinguish LD from pneumonia caused by other etiologic agents. However, there are some clinical clues to assist in the diagnosis (Table 3.2).6
{| class="wikitable"
|+
!Table 3.2 Clinical clues to Legionnaires’ disease
!
|-
|'''CLUE'''
|'''EXAMPLE'''
|-
|'''PATIENT HISTORY AND PHYSICAL EXAMINATION'''
|
|-
|Presence of an epidemic or documented source of infection
|Family, friends or associates with similar infection and exposure
|-
|Prominent neurologic or gastrointestinal symptoms
|Pneumonia with confusion, nausea and vomiting
|-
|Non-response to aminoglycosides or beta-lactam antibiotics
|Worsening condition after 5 days on antibiotics
|-
|'''LABORATORY RESULTS OF PATIENT'''
|
|-
|Gram stain of sputum with many neutrophils but no bacteria
|Laboratory reports showing many neutrophils and few normal flora or no bacteria
|-
|Nodular peripheral infiltrates in chest radiographs
|Progression of unilateral opacities to bilateral nodular infiltrates over several days
|}

It is important to remember that a clinical diagnosis of LD always has to be confirmed with specialised laboratory tests. As not all laboratories are equipped to perform these tests routinely, the tests have to be specifically requested by the physician. Table 3.3 highlights some of the most commonly used laboratory tests.12

*'''Culture''' of Legionella organisms from clinical samples is still the gold standard for diagnosing LD. The technique is highly specific, provided appropirate samples are used, and about 1.5 to 3 times more sensitive than immunofluorescence. Transtracheal aspirates are best for culture, but sputum, bronchial aspirates, pleural exudates, lung biopsies as well as wound swabs and even autopsy material have been used successfully.11 Disadvantages of the culturing of legionellae for diagnostic purposes include possible inhibition by non-legionellae organisms present in the sample, slow growth and difficulties in distinguishing legionellae from other organisms on solid media. These factors must be taken into account when choosing a laboratory to test clinical samples for LD.

*'''Immunofluorescence''' is useful to detect antigens (direct immunofluorescence) or antibodies (indirect immunofluorescence) in clinical samples in cases where culture is not possible. Cross reactions with organisms other than Legionella in the direct immunofluorescence (DFA) test may cause false positive results, making accurate interpretation of the results essential.11,13 Indirect immunofluorescence (IFA) is the most specific of the currently available serological tests for LD. It is reproducible, sensitive and specific for the diagnosis of especially L. pneumophila infections, but may be affected by several factors, including the method of antigen preparation, method of antigen fixation during preparation of the reagent, the class of immunoglobulin it is designed to detect and strain differences.14,15

*'''The Legionella Urinary Antigen test5''' is a relatively inexpensive and rapid diagnostic test, but only detects infections caused by L pneumophila Serogroup 1. The test is commercially available as a radioimmunoassay (RIA) or an enzyme linked immunosorbent assay (ELISA). An advantage of this test is the relative ease with which urine samples can be obtained, especially in patients with a non-productive cough. Legionella antigens may persist in the urine of some patients for as long as one year.

*'''Serological tests''' are useful for epidemiologic studies but less valuable for physicians. Diagnosis by serology is based on a fourfold rise in antibody titre to ≥ 1:128 in paired samples (from the acute and convalescent stage of disease).13,15 However, the antibody response may not be detectable until 1-3 months after onset of illness. Single titres of ≥1:256 during convalescence in pneumonia patients is suggestive of legionellosis. Antibody screening should include both IgG and IgM because some patients may only have an IgM response.5

*Assays based on the '''polymerase chain reaction (PCR)''' have been used to detect legionellae in urine, broncho-alveolar lavage fluid and sputum. These tests are highly specific but not more sensitive than culture and are much more expensive to perform. Limitations of PCR tests include the possible presence of certain “PCR inhibitors” in sputum and blood samples. The major advantage of PCR is the rapidity of the test and the ability to detect species other than L pneumophila. PCR is not used routinely for the clinical diagnosis of LD.

{| class="wikitable"
|+
!Table 3.3 Sensitivity and specificity of laboratory tests for the diagnosis of Legionnaires’ disease
!
!
|-
|'''TEST'''
|'''SENSITIVITY (%)'''
|'''SPECIFICITY (%)'''
|-
|Culture from clinical samples
|80
|100
|-
|Direct immunofluorescence (DFA)
|33-70
|96-99
|-
|Indirect immunofluorescence (IFA)
|40-60
|96-99
|-
|Urinary antigen detection
|70
|100
|}
Source: Stout and Yu, 1997 '''WHAT TO TAKE INTO ACCOUNT WHEN INTERPRETING LABORATORY RESULTS'''

*Both IgM and IgG should be measured simultaneously.
*Diagnostic IgM titres will provide an earlier diagnosis than IgG because they indicate a primary immune response.
*Results obtained by the IFA should always be interpreted in conjunction with the clinical presentation of the disease.
*Titres below the diagnostic level together with clinical manifestations may be useful for early provisional diagnosis of Legionnaires’ disease; but diagnosis by IFA is usually retrospective.
*The interpretation of the IFA should take into account the variation in the time of appearance of antibodies, the types of antibodies produced and the length of time the antibodies are detectable in sporadic cases, as well as the prevalence of antibodies in the population from which the patient comes.
*The type of reagents used for IFA tests may influence the results: ether-killed, formalin-killed or heat-killed antigens vary in sensitivity and specificity and this should be taken into account in the interpretation.
*False negative results may be reported because a long time is needed for seroconversion to occur and not all species and serogroups are detectable by this method.
*Seroconversion (a fourfold rise in titre to at least 1:128) is considered as a presumptive positive result.
*A single titre of 1:256 or higher is regarded as a presumptive positive result.
*Serological results should preferably be confirmed by culture.
*In communities with low antibody prevalence, a single titre of 1:128 may be diagnostic and where the prevalence is high, a single titre of 1:256 may still provide only presumptive evidence of infection.
*Low titres usually indicate past infections.
*When titres to multiple antigens are raised, the titre that is fourfold higher than the others is considered to be diagnostic.
*In epidemiological studies diagnostic titres are usually one twofold dilution higher than for sporadic cases.

===HISTOLOGY===
Pulmonary lesions usually consist of a mixture of neutrophils and macrophages, fibrin, proteinaceous material and red blood cells. Neutrophils and macrophages are often present in the centre of a lesion with mainly macrophages around the periphery.

Intracellular bacteria are present in both neutrophils and macrophages. Further away from the site of acute inflammation, bacteria are mainly seen inside the macrophages.10

 
[[File:FIGURE 3.3.jpg|center|thumb|500x500px|Figure 3.3 Histological section of lung of Legionnaires disease patient]]
 

===CHEST RADIOGRAPHS===
Radiographic features in Legionnaires’ disease are mostly non-specific, and absent in Pontiac fever. Abnormalities occur from the third day post infection in most Legionnaires’ disease patients and usually do not correlate well with the severity of illness.11 However, the abnormalities correlate with the presence of the Legionella bacterium in sputum. The time required to show clearing of infiltrates on radiographs is variable and may range from 1-4 months. Some patients show diffuse alveolar damage. In the majority of patients with Legionnaires’ disease:

*Initial involvement is unilateral, predominantly in the lower lobe
*Bilateral involvement has been described
*Initial densities are poorly marginated, homogenous, rounded, occur either on the periphery or in the centre of the lung and may be mistaken for pulmonary infarction
*Pulmonary densities enlarge during later stages of disease
*Pulmonary densities have a typical ground glass appearance or dense consolidation
*Total opacification of the lung may occur
*Pleural effusions are present in 24-63% of cases caused by L pneumophila
*Pleural effusions are uncommon in L micdadei infections
*Hilar adenopathy seldom occurs
*Cavitation may occur in immunocompromised patients
*Cavitation rarely occurs in L micdadei infections

Figure 3.4 Chest radiograph of Legionnaires’ disease patient

===TREATMENT===
Treatment of LD requires the use of antibiotics. However, many antibiotics effective against other bacterial pneumonias are ineffective against Legionella as these drugs do not penetrate the pulmonary cells (alveolar macrophages) where infectious Legionella bacteria thrive.

Erythromycin was historically the drug of choice for the treatment of Legionnaires’ disease, but the newer macrolides (azithromycin) and quinolones (ciprofloxacin, levofloxacin, moxifloxacin, gemifloxacin, trovofloxacin have superior in vitro activity and greater intracellular and lung-tissue penetration.12 Other agents that have been shown to be effective include tetracycline, doxycycline, minocycline, trimethoprim- sulfamethoxazole.12 Rifampin is recommended as part of combination therapy with a macrolide or a quinolone for patients who are severely ill. The total duration of therapy is usually 10-14 days; however a 21-day course may be needed for immuno-compromised patients or those with extensive evidence of disease on chest radiographs.12

When LD patients are treated with appropriate antibiotics near the onset of disease, the prognosis is usually very good, especially if there is no underlying illness compromising the immune system. For patients with compromised immune systems, including transplant patients, any delay of appropriate treatment may result in complications, prolonged hospitalisation and death. However after successful treatment and hospital discharge, many patients still experience fatigue, loss of energy and difficulty concentrating. These symptoms may persist for several months, but complete recovery usually occurs within one year.

===PONTIAC FEVER===
Pontiac fever is an acute, self-limiting, flu-like illness without symptoms of pneumonia. The first outbreak of Pontiac fever was reported in Pontiac, Michigan, in 1968.16

It is characterised by high fever, chills, myalgia and malaise but without the pneumonia or cough typical of Legionnaires’ disease. Some authors suggest that it is a hypersensitivity pneumonitis, caused either by infection with a free-living amoeba called ''Acanthamoeba'' filled with legionellae or as a result of a toxic reaction to the organism. The incubation period is short, ranging from 1 – 3 days, and the attack rate high, exceeding 90% in some cases. The fatality rate is low.

Pontiac fever symptoms usually resolve spontaneously within one week, only symptomatic treatment is needed and the chest radiograph is clear. There is no evidence of secondary spread of the infection in Pontiac fever. Diagnosis can only be made by seroconversion, which may be delayed for up to 6 weeks after onset of symptoms. Cases of PF have been linked to ''L pneumophila, L feelei and L anisa''. Complete recovery usually occurs in 2 – 5 days without medical attention.

== CHAPTER 4 ==

=== SURVEILLANCE FOR LEGIONELLA ===
A major aspect of biosafety in the workplace is the assessment of hazards and risks of infection (environmental surveillance) and disease in workers (clinical surveillance). ENVIRONMENTALSURVEILLANCE Environmental surveillance is essential for the long term success of any water treatment program for Legionella to provide baseline environmental information to ensure the efficiency of disinfection and water treatment programmes and to control the risk of infection in events of mechanical failures and human error. The risk of contracting legionellosis can be summarised in terms of three factors, as summarised in Table 4.1. Table 4.1 Factors determining the risk of legionellosis Proliferation potential This potential exist in nearly all water systems and depends on many factors, including:  Presence of microbial biofilms  Diversity of microorganisms present  Availability of nutrients Exposure potential Certain industrial processes produce aerosols during their function. These aerosols can be aspirated (breathed deep into the lung) if the particle size is small enough (< 8 µm in diameter). Assessment of exposure potential thus focuses on the proximity of aerosol-generating systems to human populations. Population susceptibility The most susceptible individuals are elderly people (especially males), heavy smokers, alcoholics, patients with chronic pulmonary disease and immuno-suppressed people. 1 Source: McCoy 2004 4.1 RISK ASSESSMENTS A risk assessment is a scientifically based process used to estimate the likelihood of adverse effects occurring, taking into account the exposure (hazard), the level and nature of the risk and the target population. Risk assessments can be either quantitative or 1 qualitative. 4.1.1 Quantitative risk assessments Quantitative risk assessments involve the establishment of dose-effect and dose-response relationships in likely target individuals and populations. For a quantitative risk assessment to be successful, dose-response assessments, the extent and duration of human exposure and characterisation of the possible consequences resulting from exposure have to be determined 1 and quantified. Quantitative risk assessments are not possible for hazardous biological agents (including Legionella) for several reasons. Firstly, exposed people have varying degrees of susceptibility to infection. Secondly, water sources usually contain a diverse mixture of biological contaminants which may change rapidly over short periods of time. Thirdly, the contaminants present and the levels in which they are present are only applicable at the time and area sampled and the interactions among all these 1 biological agents present in the source and environment make exposure assessment extremely difficult. 4.1.2 Qualitative risk assessments Qualitative risk assessments on are done to “document site-specific conditions and recommendations for reducing the risk, if 1 necessary, and to establish assignments for actions, communications, training and management responsibilities”. Anumber of schemes have been developed to provide some form of risk ranking and risk scores to simplify these assessments 1 and to guide the water management plan. An example of a risk ranking for legionellosis is provided in Table 4.2. For example, if a system falls into Risk Category A, the frequency of testing, cleaning and disinfection and monitoring should be increased until the system falls into a lower Risk Category, when the rate of testing, cleaning and monitoring can be reduced again. 19 Table 4.2 Risk classification for legionellosis HIGHEST RISK LOWEST RISK RISK CLASSIFICATION A B C D CRITERIA MATCHES ANY OF THE RESPONSES BELOW MATCHES ANY OF THE RESPONSES BELOW AND NONE IN A MATCHES ANY OF THE RESPONSES BELOW AND NONE IN A OR B MATCHES ANY OF THE RESPONSES BELOW AND NONE IN A, B OR C Stagnant water  System idle more than once a month  Re-circulation pump not timed  Dead-legs present  A plus timed recirculation pump  Any single factor in A  System operates continuously  No dead-legs Nutrients and growth  Contaminated water  No corrosion control  Wet surfaces open to sunlight  Any two factors in A  Any one factor in A  No factors in A Water quality  No automated biocide dosing protocol  No water treatment program  No automated biocide dosing  No water treatment program in place  Automated biocide dosing  No water treatment program in place  Automated biocide dosing  Water treatment program in place Equipment design and operation  No system design review  No system operation and performance review  No drift eliminators  Drift eliminators for cooling towers in place  Same as B with at least one review lacking  System design review in place  System operation and performance review in place  Good drift eliminators Location and access  Located in healthcare or residential care facility  Large numbers of people exposed  Same as A but moderate numbers of people exposed  Same as B but few people exposed  Not located near susceptible people 1 Source: McCoy 2004 4.2 THE RISK ASSESSMENTPROCESS The four most important steps in the risk assessment process are to get an overview of the operation of the water distribution system, to conduct a walk-through investigation of the building or facility, to assess the results of the walk-through to determine an 2,3,4 appropriate course of action and to recommend appropriate control actions. These steps are explained in more detail below. STEP 1 GET AN OVERVIEW OF THE WATER DISTRIBUTION SYSTEM OPERATION Ask the facilities engineer or an experienced member of the building staff, who has knowledge of the design and current operation of the system to explain the system and to assist in the walk-through investigation. The overview should include inspection of: ! Plumbing systems, heating/ventilation/air-conditioning (HVAC) systems and other water reservoirs as summarised in Table 4.3 20 ! Maintenance records of all water systems, including records of temperature checks on potable water, details of visual and physical checks of cooling towers and reports of water quality assessments and chemical treatment that may have been performed ! Location of parts of the system where there may be stagnant water ! The presence of cross-connections between potable and non-potable water systems ! The condition and type of back flow prevention devices used at these connections ! Any recent major maintenance actions performed or major changes in the system ! Determine whether recent or frequent losses of water pressure have occurred from the incoming supply ! Keep in mind that the failure of a back flow prevention device under loss of pressure can result in contamination of the water system Table 4.3 Areas to include when doing an overview of a waterdistribution system Plumbing systems Hot and cold potable water systems Water heaters Water coolers Distribution piping Water treatment equipment (eg. water softeners, filters) Connections to process water systems (not protected by backflow preventers) Storage tanks Heating, ventilation and airconditioning (HVAC) systems Cooling towers Evaporative condensers Fluid coolers Direct and indirect evaporative cooling equipment Humidifiers Location of fresh air intakes relative to water sources Air washers for filtration Miscellaneous reservoirs Decorative fountains Plant misters Whirlpools and spas Tepid water eye washes Safety showers Cooling water for industrial processes 2 Source: <nowiki>http://www.nalco.com</nowiki> STEP 2 CONDUCT A WALK-THROUGH INVESTIGATION OF THE FACILITY Table 4.4 The walk-through investigation WHAT TO DO WHEN ! Check sample transport requirements and receiving times of laboratory before investigation ! Get as much information as possible from staff before investigation ! Go through checklist and make sure you are prepared before investigation ! Check water temperatures while sampling for Legionella ! Check hot water tanks and related piping during investigation ! Check cooling towers during investigation ! Check water quality during investigation ! ! ! ! ! WHO SHOULD BE PRESENT? The person who knows most about the building, particularly the domestic water system Aplumbing engineer if possible Aplumbing contractor who knows the building if possible Arepresentative from the company that services the HVAC system The water treatment specialist who services the cooling tower 21 EQUIPMENT NEEDED ! The floor plan (arrange in advance if possible) ! Drawings of plumbing if available (arrange in advance if possible) ! Inspection checklist ! Camera ! Knife ! Pliers or channel locks ! Measuring tape SAMPLING KITS AND EQUIPMENT TO TAKE WITH ! Thermometer ! Chlorine kit ! Iron kit ! pH meter ! Total dissolved solids (TDS) kit ! Hardness kit ! Calibration fluid ITEMS NEEDED FOR LEGIONELLA SAMPLING ! Sampling log (see example) ! Sodium thiosulfate ! Cooler bag and other materials needed for packaging of sample for transport ! Documentation from courier or transport agency ! Plastic bags for packaging of samples ! Sterile swabs ! Sampling bottles ! Labels for bottles ITEMS NEEDED FOR SAMPLING FOR THE TOTAL BACTERIAL COUNT (TBC) ! Sampling bottles ! Sampling log sheets ! Cooler bag and other materials needed for packaging of sample for shipping or transport ! Documentation from courier or transport agency ! ! REMEMBER The temperature may be below the gauge temperature of the heater due to heat stratification CHECKLIST FOR FAUCETS CONNECTED TO EACH WATER HEATER ! Maximum temperature of each location that is “close (C)”, “intermediate (I)” or “far (F)” from the heaters ............................................................................................................ REMEMBER You may have to run the water for several minutes before it reaches a maximum temperature at “far” locations CHECKLIST FOR COLD WATER STORAGE TANKS USED FOR RESERVE WATER OR FOR MAINTAINING HYDROSTATIC PRESSURE ! InitialTemperature (°C) .......................................................................................................................... ! Potential for stagnation: high (H), medium (M) or low (L)........................................................................ ! Temperature of cold water line at various locations Location ............................................................... Temperature (°C) ......................................... Location ............................................................... Temperature (°C) ......................................... Location ............................................................... Temperature (°C) ......................................... Location ............................................................... Temperature (°C) ......................................... Record both initial temperature and final equilibration temperature on cold water lines ...................... REMEMBER Tanks should be protected from temperature extremes and should be covered to prevent stagnation CHECKLIST FOR EACH STORAGE-TYPE HOT WATER HEATER Temperature of water drawn from it (°C) ................................................................................................. Presence of rust and scale ......................................................................................................................... 22 CHECKLIST FOR COOLING TOWERS, EVAPORATIVE CONDENSERS AND FLUID COOLERS ! Visual evidence of biofilm growth, scale build-up and turbidity ........................................................... ! The location of the tower relative to fresh air intakes ............................................................................ ! Proximity to sources such as kitchen exhausts, leaves, plant materials, or other sources of organic material that may contribute to Legionella growth .............................................................................................. CHECKLIST FOR COOLING TOWERS ! General physical and mechanical condition ........................................................................................... ! Presence and condition of drift eliminators ............................................................................................ ! Basin temperature of water (the tower is working) ................................................................................ REMEMBER Wear appropriate respiratory protection (half face-piece respirator and HEPA filter cartridge) during examination if cooling tower is operating SUMPS FOR COOLING TOWER, EVAPORATIVE CONDENSER AND FLUID COOLERS ! Location and condition ............................................................................................................................ ! Location of any cross-connections between potable and non-potable systems ......................................... REMEMBER Sumps are sometimes located indoors to prevent them from freezing. Cross-connections may be present to supply a back-up source of cool water to refrigeration condenser units or to supply secondary cooling units STEP 3 ASSESS THE RESULTS OF THE WALK-THROUGH TO DETERMINE AN APPROPRIATE COURSE OF ACTION Table 4.5 When is additional action necessary? NO FURTHER ACTION Operating temperatures measured in water heaters is 60°C Delivery temperature at distant faucets is ? 50°C No other potential problems observed TAKE FURTHER ACTION Poor maintenance Operating temperatures below minimums mentioned above STEP 4: RECOMMEND CONTROLACTIONS Remember! These actions may include disinfection of the potable water system as outlined in the section on disinfection 23 Table 4.6 Recommended control actions ACTION EXPLANATION Actions to limit the growth of organisms in water systems: Elimination of dead legs in the plumbing system Insulation of plumbing lines Installation of heat tracing to maintain proper system temperatures Elimination of rubber gaskets Removal or frequent cleaning of plumbing fixtures (eg aerators and shower heads) Water sampling to confirm the presence of Legionella: Not necessary at this stage BUT Customer may want to obtain background information, in which case sampling for Legionella will be helpful To ensure that corrective actions are successful: Sample water after corrective action BUT Customer may want to collect samples before corrective action to assess the extent of the problem but this is not normally done The customer should take the necessary corrective action, even if the pre-sampling tests are negative for the following reasons: Water sampling may produce false-negative results A contaminated portion of the system may have been missed The absence of legionellae at the time of sampling does NOT ensure that the system will remain negative at a later date Limited corrective actions that will not be sufficient: Raising water heater temperature without evaluation of system points of stagnation, heat loss and heat gain, cross-contamination and other factors that may contribute to the growth of Legionella bacteria. LEGIONELLA RISK ASSESSMENT DATA SHEET GENERAL INFORMATION Name of organisation Contact person 1 Contact person 2 Contact person 3 Site address Mailing address Building/area size Building age Type of building 24 RESULTS FROM PREVIOUS LEGIONELLA TESTING DATE RESULT Cooling towers Hot water tanks Outlet swabs Hot water outlets Cold water outlets Mixed outlets Incoming water 25 USEFUL QUESTIONS TO ASK ABOUT THE FACILITY WHEN DOING A RISK ASSESSMENT FOR LEGIONELLA(SOURCE: FREIJE 2001) Incoming mains Number Configuration Water source City - ground City - surface Utility: Private well Water usage Obtained from Water bills Fixture count Meter reading Other Deadlegs Present Policies Past construction Aerators Yes No Type Cold pipes location relative to hot Above Below Same level Pipe material Pipe insulation Cold Hot Both Type used Drinking fountains On chilled loop Individual 26 Fire sprinkler above ducts Yes No Water hammers arrestors or air chambers Water hammers Air chambers Both Sediment on water filters Yes No Other sediment gathering equipment Yes No Describe Connection control and/or backflow devices Yes No Faucets and showerheads Age Condition Water softened Cold water Yes No How Hot water Yes No How Water pressure shock Incidents Brown colour Building units closed off temporarily Yes No Major construction activities Yes No Dates Eye wash stations Mixed Cold Emergency showers Mixed Cold 27 Ice machines present Yes No Decorative fountains present Yes No Piped in coffee/tea/cooldrink centres present Yes No Rubber hoses present Yes No Misters for plants/food/comfort present Yes No Other equipment where water flow through that may produce a spray/mist Yes No Can windows be opened? Yes No HVAC systems +Condition of coils Overall condition Drainage of drip pans Humidifiers in duct? Hot water system Number of HW loops Number of CW loops HW recirculating? CW recirculating? Design temp at tank Design temp at taps Regulators Mixing valves Sensors to detect failures CW storage tanks present? Are they covered? Heaters or sunlight? 28 HOT WATER SYSTEM INSPECTION Model number Serial number Age Horizontal/vertical Condition Insulation Temp on gauge Temp from drain Temp of returning water Capacity/turnover Cleaning regimen Cleaning frequency All pumps used daily? Piping arrangement Draw diagram on separate sheet and attach 29 COOLING TOWER INSPECTION In-house identification Location Make and model Serial number Size Age Basin drainable? Cycling of each Months operating Water treatment company Contact details Cleaning frequency Who does the cleaning How is cleaning done? Is basin fully drained? Excessive foaming? Oily film on surfaces? Scum? Condition of drift eliminators Air bypassing: Around edges? Through holes in tower casing? Fill exposed to sunlight Basin exposed to sunlight Louvres/fill clogged? Louvres/fill damaged? Louvres/fill scale present? Louvres/fill algae present? Filters SAND BAG CARTRIDGE Pressure drop 30 Centrifugal separators Outlet strainers Pressure drop Corrosion/deterioration on Structural members? Safety rails? Ladders? Fasteners? Basin? Water leaks present? Air leaks present? Sump water level Cooling water temp Accessible to passers by? Distance from road Distance from parking Distance from sidewalks 31 COOLING TOWER INSPECTION CHECKLIST 5 Source: Freije 2001 BUILDING TOWER NAME/NUMBER INSPECTOR’S NAME DATE OF INSPECTION SAND FILTERS Water leaks? YES NO Suction air leaks? YES NO Pre-strainer clogged? YES NO Channeling in sand filter media (check quarterly) YES NO Operating pressure If YES, clean the media or replace it with filter sand designed specifically for cooling towers and evaporative condensers (not swimming pools). Clean the under-drain assembly while the media is removed. CENTRIFUGAL SEPARATORS Pressure drop Acceptable based on manufacturer’s chart? YES NO Flow rate Purge operation functional? YES NO UNUSUAL NOISE OR VIBRATION IN Pumps? YES NO Motors? YES NO Fans? YES NO Mounting hardware? YES NO OUTLET STRAINERS In place? YES NO Clogged? YES NO BAG AND CARTRIDGE FILTERS Pressure drop Acceptable based on manufacturer’s recommendations? YES NO If not, clean or replace TOWER STRUCTURE AND CASING Water leaks? YES NO Air leaks? YES NO 32 CORROSION OR OTHER DETERIORATION ON Structural members? YES NO Safety rails? YES NO Ladders? YES NO Fasteners? YES NO Basin? YES NO LOUVERS, FILL AND DRIFT ELIMINATORS Clogged? YES NO Damaged? YES NO Excessive scale or algae growth? YES NO If yes, clean with 6,895 – 10,343 kPa (1,000 – 1,500 psi) water, being careful not to damage fill and eliminator components WATER DISTRIBUTION Is the water distribution balanced? YES NO If not, unclog nozzles SEDIMENT BUILD-UP Sediment build-up around heater elements? YES NO FANS Do fans start and stop properly? YES NO VIBRATION Are the vibration switches operating properly? (check at least annually) YES NO SEASONAL OPERATION Are the seasonal systems working (check at least 3 months before winter) YES NO Are there any parts needed? YES NO If YES, what is needed? Are there any repairs necessary? YES NO If YES, what is needed? 2133 Describe action taken in response to above inspection (include dates): QUESTIONS FOR INFECTION CONTROL COORDINATOR (IF APPLICABLE) History of cases Cleaning of hydrotherapy baths and pools Practices for use and cleaning of portable humidifiers Practices for use and cleaning of nebulizers and other semi-critical respiratory equipment Water treatment for dialysis Contact details: Dental unit present? How is it treated? Contact details: Clinical tests for Legionella available? Policy for testing patients/workers for Legionella? 34 CHECKLIST FOR LEGIONELLA SAMPLING HW tank PRE-FLUSH POST-FLUSH Incoming water Faucets and showerheads Cooling make-up water Decorative fountains Cooling tower basins WATER QUALITY TESTS SAMPLE LOCATION pH Free chlorine Total chlorine Hardness TDS Iron TBC Coliforms WATER TEMPERATURES SAMPLE LOCATION HW after 1 minute (°C) CW after 1 minute (°C) 35 EXAMPLE OFSAMPLING LOG / REQUESTFORM REQUESTFOR TESTING OFWATER SAMPLES FOR LEGIONELLA COMPANYDETAILS .................................................................................................................................................................................................. CONTACTPERSON .................................................................................................................................................................................................. CONTACTDETAILS TEL........................................... FAX ............................................. E-MAIL................................................................ NAME OF PERSON WHO COLLECTED SAMPLES ............................................................................................................................... COLLECTION SITE .................................................................................................................................................................................................. SAMPLE NO LOCATION TYPE TIME COLLECTED COMMENTS Received by ……………………………..……….... Date ……………………….. Time ……………… HEALTH SURVEILLANCE Health surveillance can be defined as the “ongoing collection, comparison, analysis and dissemination of data relevant to public health issues”. The main objectives of health surveillance are to identify disease patterns in different population groups, to develop prevention strategies, to allocate resources for prevention and treatment and to educate health professionals and the general public. Health surveillance can take the form of: ! The notifiable disease reporting system (the first step in the surveillance cycle) ! Laboratory based surveillance (for diseases that can be monitored accurately through the laboratory data used for confirmation of the disease) 36 ! Hospital-based surveillance (where hospital discharge information and mortality data are used to monitor trends and disease burden in a particular area) ! Population-based surveillance (where data from a well-defined population are collected and analysed) DISEASE NOTIFICATION Disease notification serves as a means of collecting data on diseases that are considered to be of public health importance and is used world wide. Most countries (including South Africa) have a routine notification system requiring health professionals to report the occurrence of cases and deaths related to certain notifiable conditions. In South Africa, 39 medical conditions are currently 6 notifiable (Table 4.7). The notification system in South Africa is based on Health Act No. 63 of 1977 together with certain Regulations on the reporting of specific diseases to the Local, Provincial and National Health Departments. Table 4.7 Notifiable conditions in South Africa  Acute flaccid paralysis  Leprosy  TB (pulmonary) Any person (not necessarily a health care worker) may report a notifiable condition to a local authority via fax, mail or telephone. The relevant notification form is then completed by the local authority or district office, and submitted to the provincial office, which in turn summarises the cases and deaths for each notifiable condition (even if no cases or deaths occurred during that period) and sends the summary to the national office. WHO IS RESPONSIBLE FOR NOTIFICATION? The first health care professional or facility with whom a patient presenting with one of the notifiable medical conditions comes into contact is expected to notify the case (or death). This includes clinic personnel, infection control nurses, other hospital staff, and public and private medical practitioners. In cases where the patient had no contact with a health care professional, a member of the community is required to report the case. WHYIS NOTIFICATION SO IMPORTANT? Healthcare professionals have a legal obligation to report cases of notifiable conditions. The process of notification alerts outbreak response teams, resulting in appropriate and timely interventions, in turn assisting in the prevention of spread of communicable diseases. In addition, the notification system provides information on the status and trends of communicable diseases in the country. THE NOTIFICATION PROCESS There are certain forms to be filled in when reporting a case or death. These are available from the regional health office, the local Communicable Disease Coordinator or the provincial stores section. ! Form GW17/05: Initial diagnosis (to be completed immediately and containing finer details of the patient and the diagnosis) ! Form GW17/03: Line list of cases (to be completed weekly) ! Form GW17/04: Line list of deaths (to be completed weekly) Notifications are done using GW17/05 forms. The structure of the system, process of obtaining the forms and persons to which the forms are sent differ considerably between, and even within provinces. People at the provincial health information offices, however, are conversant with specific details of the system in their province, and nurses and doctors are encouraged to contact them for specific details about how to go about notifying cases and deaths of the diseases above. Alist of telephone numbers and addresses 7 of these contact people is included at the end of this article. Asemi-detailed overview of the process is described below. The GW17/05 forms are required to be completed as fully as possible, although information on patient's age, sex or race may be omitted only if it is not available. All other applicable information should be filled in, especially details relating to the place and date of infection, the disease being notified and whether a case or death is being notified. The contact people in the relevant provincial health information office will be able to furnish you with the details of the specific office to which the notification forms should be 37 sent. The steps to follow when reporting notifiable conditions are summarised in Table 4.8. Table 4.8 Steps in the notification process STEP 1 Diagnose and confirm that the patient is suffering/has died of a notifiable condition. STEP 2 Obtain the necessary documentation: Form GW 17/5  In the case of death the condition should be reported twice, first as a case and then as a death. STEP 3 Complete all the forms and send them to the relevant office:  Local Authority/Hospital/District responsible for disease containment (fill in Form GW 17/3);  Regional Office (the Health Information Unit);  Provincial Office (the Health Information Unit);  National Department (Directorate HSR and Epidemiology) 7 Source: The notification system in a nutshell. Remember! When workers complain of symptoms, the first question to be answered is not "How do we fix the building?", but rather: “Why to they have symptoms?". In other words, to address health complaints effectively, a health evaluation is absolutely essential. A systematic approach to legionellosis in the work environment is crucial.

==Acknowledgements==
Delene Bartie (CB Scientific)- 2023

==References Chapter 3==

#Dowling JN, McDaevitt DA, Pasculle AW. Isolation and preliminary characterization of erythromycin-resistant variants of Legionella micdadei and Legionella pneumophila. Agents Chemother. 1985, 27 (2): 272-274.
#MacFarlane JT, Miller AC, Smith WH, Morris AH, Rose DH. Comparative radiographic features of community acquired Legionnaires’ disease, pneumococcal pneumonia, Mycoplasma pneumonia and psittacosis. Thorax 1984, 39: 28-33.
#Boldur I, Beer S, Kazak R, Kahana H, Kannai Y. Predisposition of the asthmatic child to legionellosis? Isr. J. Med. Sci 1986, 22 (10): 733-736.
#Kurtz JB. Legionella pneumophila. Am. J. Occup. Hyg. 1988, 32 (1): 59-61.
#Shapiro M. Unusual epidemiologic and clinical manifestations of legionellosis: a review. Isr. J. Med. Sci. 1986, 22 (10): 724-727.
#Yu VL. Legionella pneumophila (Legionnaires’ disease). In: Mandell, Douglas and Bennet (eds). Principles and practice of infectious disease. 1990, Third Edition, Churchill Livingstone.
#Ratshikhopha ME, Klugman KP, Koornhof HJ. An evaluation of two indirect fluorescent antibody tests for the diagnosis of Legionnaires’ disease in South Africa. South African Med. J. 1990, 77: 392-395.
#Bartie C and Klugman KP. Exposures to Legionella pneumophila and Chlamydia pneumoniae in South African mine workers. Int. J. Occup. Environ. Health 1997, 3: 120-127.
#Maartens G, Lewis SJ, de Goveia C, Bartie C, Roditi D, Klugman KP. “Atypical” bacteria are a common cause of community acquired pneumonia in hospitalised adults. South African Med. J. 1994, 84: 678-682.
#Winn 1991
#Roig J, Aguilar X, Ruiz J, Domingo C, Mesalles E, Manterola J, Morera J. Comparative study of Legionella pneumophila and other nosocomial-acquired pneumonias. CHEST 1991, 99: 344-350.
#Stout JE, Yu VL. Legionellosis. New Engl. J. Med. 1997, 682-687.
#Ruf B, Schürman D, Horbach I, Fehrenbach FJ, Pohle HD. Prevalence and diagnosis of Legionella pneumonia: a 3-year prospective study with emphasis on application of urinary antigen detection. J. Inf. Dis. 1990, 162: 1341-1348.
#Harrison TG, Dournon E, Taylor AG. Evaluation of sensitivity of two serological tests for diagnosing pneumonia caused by Legionella pneumophila serogroup 1. J. Clin. Pathol. 1987, 40: 77-82.
#Pastoris MC, Ciarrochi S, Di Capula A, Temperanza AM. Comparison of phenol- and heat-killed antigens in the indirect immunofluorescence test for serodiagnosis of Legionella pneumophila serogroup 1 antigens. J. Clin. Microbiol. 1984, 20 (4): 780-783.
#Kaufmann AF, McDade JE, Patton CM, Bennett JV, Skalyi P, Feeley C, Anderson DC, Potter ME, Newhouse VF, Gregg MB, Brachman PS. Pontiac fever: isolation of the etiologic agent (Legionella pneumophila) and demonstration of its mode of transmission. Am. J. Epid. 1981, 114 (3): 337-347.
#Dennis PJ (1993). Potable water systems: insights into control. In: Barbaree JM, Breiman RF and Dufour AP (eds). Legionella: Current status and emerging perspectives. American Society for Microbiology, Washington DC. Pp 223-225.
#Colbourne JS and Dennis PJ (1985). Distribution and persistence of Legionella in water systems. ''Microbiol. Sc.'' '''2''': 40-43.
#Muraca PW, Stout JE, Yu VL and Yee YC (1988). Mode of transmission of ''Legionella pneumophila''. A critical review. ''Am. J. Hyg. Assoc.'' '''49''': 584-590.
#Yamamoto H, Sugiura M, Kusunoki S, Ezaki T, Ikedo M and Yabuuchi E (1992). Factors stimulating propagation of legionellae in cooling tower water. ''Appl. Environ. Microbiol.'' '''58''': 1394-1397
#[[Legionella Control#cite%20ref-:0%205-0|Jump up to:5.0]] [[Legionella Control#cite%20ref-:0%205-1|5.1]] Freije MR (1996). Legionella control in healthcare facilities: A guide for minimising risk. HC Information Resources, Inc. United States of America. P 8
#MarrieTJ, Haldane D, Bezanson G and Peppard R (1992). Each water outlet is a unique ecological niche for ''Legionella pneumophila''. ''Epid. Infect.'' '''108''': 264-270

[[Category:Legionella Control]]
[[Category:Infection Prevention and Control]]
[[Category:Water Distributions Systems]]
<references />

Legionella Control

2020-11-16T08:46:41Z

Tmojanaga: /* Section 1 */

Sustainability

2020-10-29T04:28:32Z

Tmojanaga: /* INTRODUCTION */

==CHAPTER 1==

===1.1 HISTORY===
Legionnaires’ disease was first described after a pneumonia outbreak at an American Legion Convention held in Philadelphia during 1976. In total, 182 delegates were affected and 29 died before workers at the Centers for Disease Control and Prevention (CDC) based in Atlanta, USA isolated the causative organism in January 1977. The organism was placed in the family Legionellaceae, genus Legionella to commemorate the first victims of the disease. The first species was named Legionella pneumophila (Greek for “lung loving”).

It soon became clear that legionellae were not really new; retrospective studies showed that an organism isolated for the first time in 1944 (called Tatlockia micdadei) actually belonged to the genus Legionella. The first strain of L pneumophila was isolated already in 1947 from a guinea pig that had previously been inoculated with blood from a patient with what was called an “unknown febrile disease” at the time. The two decades following the discovery of the family Legionellaceae was marked by rapid developments in Legionella detection and the identification of numerous new species. Twenty-eight new Legionella species and two “Legionella-like amoebal pathogens” (LLAPs) (LLAP-1 and LLAP-6) were isolated during the 1980s, mostly from sources in the USA. The 1990s were marked by an increase in Legionella isolation from countries in Europe and Australia with fifteen new Legionella species being described for the first time.

More than half of the currently known Legionella species are potentially pathogenic to humans. L. pneumophila is still implicated in >80% of infections; however, as more species are isolated from environmental sources worldwide, even those species not yet associated with disease should be considered as potentially pathogenic until proven otherwise. For example, L. longbeacheae, often isolated from potting soil, is considered the most common cause of legionellosis in Australia. Legionellae are faintly staining gram negative, rod-shaped, non acid fast bacteria that to not form spores or capsules. All species except L. oakridgensis are motile. Legionellae are typically between 0.3 and 0.9 µm wide and 1- 20 µm long. However, shorter forms measuring 1- 2 µm in length are often observed in clinical specimens or under conditions of iron deprivation.

The ability of legionellae to grow in water is influenced by several factors. They can grow at temperatures between 20°C and 60°C, with optimal growth occurring between 37°C and 45°C. They prefer a pH in the range of 5.0 9.5 and only grow in the presence of Lcysteine, HCl and iron salts. Legionella-like amoebal pathogens (LLAPs) are very similar to Legionella species in that they are gram negative, infect amoebae and can survive and multiply intracellularly. However, they cannot be cultured on laboratory media. The first LLAP was isolated 1from soil in Poland in 1954 and was named Sarcobium lyticum. The next isolation of an LLAP was in England more than 20 years later. Since then, LLAPs have been isolated from various sources, mostly associated with confirmed cases or outbreaks of 2 3Legionnaires’ disease. Three of the LLAPs have since been reclassified as L. drozanskii, L. rowbothamii and L falloni. The currently known LLAPs are listed in Table 1.2.

=== 1.2 INTERACTIONS WITH PROTOZOA ===
Legionellae are slow-growing organisms that require a combination of nutrients for growth. Due to their fastidious nature and lack of antibiotic activity, they may be replaced by faster growing organisms if they do not have an alternative means of survival in aquatic environments. The fact that legionellae are ubiquitous in these environments suggests that protozoa, especially amoebae, play a supportive role in their survival and multiplication. In fact, their natural habitat, parasitic to protist hosts, has now been 4proven.

Rowbotham was the first to demonstrate interactions between legionellae and protozoa. To date, protozoa of the genera Acanthamoeba, Tetrahymena, Naegleria, Echinamoeba and Vanella species have been implicated in these interactions. Not much is known about the metabolic and physiological status of legionellae after passage through protozoa, but in vitro studies have shown changes in their physiological status resulting in iron deprivation, possibly changing the susceptibility of the released bacteria to chemical inactivation. Although they can survive extracellularly, this phase is believed to be only temporary while they are searching for new hosts to 6infect. Furthermore, it was recently documented that very few Legionella bacteria are needed to start intracellular replication. Some workers have reported a 7000 times increase in Legionella colony forming units (CFU) after intracellular replication buth there is no consensus yet as many believe that this intracellular replication cycle is not necessary for the proliferation of legionellae within mixed bacterial populations. From these studies it is clear that there is still extensive research to be done on this aspect of Legionella survival in the environment. Until more becomes known, it is unsafe to assume that the absence of protozoa within water samples prevents the survival of legionellae; as long as there are other bacterial species present, appropriate measures should be taken to prevent Legionella proliferation.

=== 1.3 HOW DOES THE INTERACTION WITH PROTOZOA BENEFIT LEGIONELLAE? ===
Amoeba trophozoites feed and multiply in water and biofilm. When conditions become unfavourable, these trophozoites are transformed into cysts with hard, impermeable outer walls that provide protection for ingested Legionella organisms. When conditions become more favourable, the cysts change to trophozoites again and the bacteria are set free. Legionellae have been 7recovered from cysts treated with 50 parts per million (ppm) chlorine suggesting a high level of protection by the cysts. This high resistance of amoebal cysts to biocides may be the mechanism for the apparent reseeding of water systems by legionellae often experienced in the water treatment industry. However, recontamination may also occur via transmission of airborne cysts acting as carriers for the legionellae.

=== 1.4 HOW IMPORTANT IS LEGIONELLA IN SOUTH AFRICA? ===
 
==INTRODUCTION==

==Purpose==
This document has been developed for the Department of Health to ensure that sustainable development is integrated into to planning and design of health facilities. The document defines sustainable development and outlines the implications of this for the built environment. It provides objectives and criteria that can be used in the development health facilities in South Africa.

==Background==
The Department of Health wish to support sustainable development in South Africa and ensure that there is an appropriate balance between economic development, social integration and protection of the environment.
Global Warming and South African legislation and policy now make it imperative that built environment projects address sustainability. However, there is limited South African guidance on how sustainable development can be integrated with built environment projects. There is also the perception that addressing sustainability in facilities will be expensive and complicated.
This document provides guidance and checklists that can be used to support the integration of sustainability into health facilities. It shows that by addressing sustainability early in projects, additional costs can be minimised and innovative, high-performance solutions that benefit society, the economy and the environment can be achieved. It also shows that achieving more sustainable facilities need not be complex but can be based on robust, sensible and simple measures.

==How to use this document==

This document provides a framework that can be used to inform the development of health facilities. It can be used in the following ways:

*'''Awareness''': This document can be used to increase awareness about sustainable development and the need to address this in built environment projects. This will lead to more rigorous debate on development options and support more innovative and sustainable solutions.

*'''Setting sustainable development targets''': This framework can be used by a development team to set explicit and challenging sustainable development targets for projects. This is done by setting quantified targets against criteria in the document and putting in place systems to ensure that these are achieved.

*'''Self-assessments''': This framework can also be used for self-assessment and to ascertain the performance of development proposals. To carry this out refer to the Facility Recommended Compliance sheet and Compliance Checklist at the end of the document. This enables different health facility development proposals to be evaluated in terms of recommended compliance. Assessment using the criteria can also inform the design process by being used to evaluate different development options. This enables optimal solutions to be developed in an iterative and efficient way.

*'''Coordinated development''': Some criteria in the document may appear not to be in the remit of, or possible in, a single development. These criteria however can be achieved through partnerships and local collaboration. This framework can be used bring together the key role players in order to develop integrated plans that enable key sustainable development objectives to be achieved.

==Structure of the guideline==
The document has the following structure:

*'''Implementing Sustainable Development''': This section provides a description of sustainable development and translates this into specific sustainable development objectives for the built environment.

*'''Built Environment Sustainable Development Objectives''': In this section more detailed guidance and checklists are provided for each of sustainable development objectives listed in the section above.

*'''Sustainability Integration Plans''': This provides guidance on plans and a structure that can be used to integrated sustainability in design and operational processes.

==IMPLEMENTING SUSTAINABLE DEVELOPMENT==

===Introduction===
South Africa faces a range of social, economic and environmental challenges. HIV/AIDs has resulted in a life expectancy dropping from 67 years in 1998 years to around 47 years currently. Unemployment is estimated to be 27% and climate change is likely to lead to increasing water stress, reduced food security and loss of species and ecosystems (DEAT 2009).
Sustainable development, which aims to achieve social and economic improvements while reducing negative environmental impacts, can be used to address these challenges. Sustainable development however can be difficult to achieve. This is because a holistic and integrated approach is required and the development sector and in particular, the construction industry, operates in a highly fragmented way. In addition, the concept of sustainable development is still new and has not been adequately translated into practical actions that can be readily implemented.
This section defines sustainable development and translates this into key built environment objectives. It also describes the role of the built environment in creating environmental and other problems and shows how integrating sustainable development considerations into construction and the built environment can make a substantial contribution to improving the social, economic and environmental performance of the built environment.

===The environmental context===
Increasing carbon emissions from human activities and a reduction in the ability of the natural environment to absorb carbon dioxide is leading to an accumulation of greenhouse gases in the upper atmosphere. These gases trap more heat in the upper atmosphere leading to global warming and temperatures are predicted to increase by 2 - 6°C OC by the end of the century (IPCC, 2007). Estimates carried out for the City of Joburg indicate that temperatures in the next 50 years may increase between 2 and 3.5°C (Hewitson, Engelbrecht, Tadross, Jack, 2005).

Within Africa, South Africa produces the highest CO2 emissions and has one of the highest CO2 emissions per GDP in the world. In 2002, carbon emissions per capita in South Africa were 8.4tonnes/capita - higher than Western European averages of 7.9tonnes/capita (SEA 2006).
Global warming is likely to impact Africa particularly negatively. The National Climate Change Response Policy Developed by the Department of Environment and Tourism outlines the following impacts (DEAT 2009a):

*Agricultural production and food security in many African countries are likely to be severely compromised by climate change and variability. Projected yields in some countries may be reduced by as much as 50% in some countries by 2020 and as much as 100% by 2100. Small scale farmers will be most severely affected.

*Existing water stresses will be aggravated. About 25% o Africa’s population (about 200million people) currently experience high water stress. This is projected to increase to between 75-250 million by 2020 and 350-600 million by 2050.

*Changes in ecosystems are already being detected and the proportion of arid and semi-arid lands in Africa is likely to increase by 5-8% by 2080. It is projected that between 25 and 40% of mammal species in national parks in sub-Saharan Africa will become endangered.

*Projected sea-level rises will have implications for human health and the physical vulnerability of coastal cities. The cost of adaptation to sea level rise could amount to 5-10% of gross domestic product.

*Human health will be negatively affected by climate change and vulnerability and incidences of Malaria, Dengue fever, Meningitis and Cholera may increase.

===The contribution of the built environment===
Construction and the built environment make a substantial contribution to global warming and play a significant role most economies. Environmental, social and economic impacts attributed to the built environment at a global scale are outlined below.

*Consumes 40% of energy use,

*Consumes 17% of fresh water use,

*Consumes 25% of wood harvested,

*Consumes 40% of material use,
*Employs 10% of the world’s work force,

*Construction is the largest employer of micro-firms (less than 10 people),

*Facilities are typically located on the most productive land (Estimated to be 250 million hectares world wide, mostly on primary agricultural land).

In South Africa the built environment is directly responsible, through electricity consumption, for over 23% of South Africa’s carbon emissions (see table below). Vehicle-based infrastructure and transport planning has resulted in transport contributing to 16% of South Africa’s CO2 emissions and an additional 18mtCO2 per year, or about 4% of South Africa’s CO2 emissions, come from the manufacture of building materials (CIDB 2009).

Sector C02 Emissions

Commercial 10%

Residential 13%

Transport 16%

Industry 40%

Mining 11%

Other 10%

Total 100%

''Figure 1: South African carbon emissions per sector''

===Defining sustainability===
Recent work by the World Wildlife Fund contributes substantially to defining sustainable development by providing quantified minimum criteria for sustainability. In the 2006 Living Planet Report, sustainability is defined as achieving an Ecological Footprint (EF) of less than 1.8 global hectares per person and an Human Development Index (HDI) value of above 0.8 (WWF 2006).

===Ecological Footprint===
An Ecological Footprint is an estimate of the amount of biologically productive land and sea required to provide the resources a human population consumes and absorb the corresponding waste. These estimates are based on the consumption of resources and production of waste and emissions in the following areas:

*Food, measured in type and amount of food consumed,

*Shelter, measured in size, utilization and energy consumption,

*Mobility, measured in type of transport used and distances travelled,

*Goods, measured in type and quantity consumed.

*Services, measured in type and quantity consumed The area of biologically productive land and sea for each of these areas is calculated in global hectares (gha) and then added together to provide an overall ecological footprint. This measure is particularly useful as it enables the impact of infrastructure and lifestyles to be measured in relation to the earth’s carrying capacity of 1.8 global hectares (gha) per person.

===The Human Development Index===
The Human Development Index was developed as an alternative to economic progress indicators and aimed to provide a broader measure that defined human development as a process of enlarging people’s choices and enhancing human capabilities (United Nations Development Programme 2007). The measure is based on:

*A long healthy life, measured by life expectancy at birth,

*Knowledge, measured by the adult literacy rate and combined primary, secondary, and tertiary gross enrolment ratio,

*A decent standard of living, as measure by the GDP per capita in purchasing power parity (PPP) in terms of US dollars.

===South African EF and HDI figures===
The figures below show that South Africa has an ecological footprint of 2.1, above the maximum required of 1.8 gha and a human development index measure of 0.66, below the minimum of 0.8 required for sustainability.

Measure South Africa Sustainability Target
Ecological Footprint (gha) 2.1 1.8
Human Development Index 0.658 0.8
{| class="wikitable"
|+
!Measure
!South Africa
!Sustainability Target
|-
|Ecological Footprint (gha)
|2.1
|1.8
|-
|Human Development Index
|0.658
|0.8
|}

For South Africa to move towards sustainability there must therefore be an improvement in both the Ecological Footprint and Human Development Index performance. The built environment has a key role in supporting this improvement.

===The legislative and policy context===
South Africa has a range of legislation and policy that aims to protect the environment and support sustainable development. Key legislation supporting sustainable development includes the South African Constitution and the National Environmental Management. These are discussed briefly below.

===South African Constitution===
The South African Constitution contains a Bill of Rights that enshrines the rights of all people in South African and affirms the democratic values of human dignity, equality and freedom. The Bill has sections covering equality, human dignity, privacy, freedom of religious belief and opinion, environment, property, housing, healthcare, food, water and social security, children, education, language and culture. Through a section on equality, the Bill requires that all people have full and equal enjoyment of these rights and freedoms:

''Everyone is equal before the law and has the right to equal protection and benefit of the law.''

Equality includes the full and equal enjoyment of all rights and freedoms. To promote the achievement of equality, legislative and other measures designed to protect or advance persons or categories of persons, disadvantaged by unfair discrimination, may be taken.
Environmental rights in the Bill of Rights include the right to an environment that supports health and wellbeing. It also requires legislation to be developed to ensure that the environment is protected and that development that does occur is both sustainable, and justifiable:

===Environment===
Everyone has the right

a). to an environment that is not harmful to their health or well-being; and

b). to have the environment protected, for the benefit of present and future generations, through reasonable legislative and other measures that ¬

#prevent pollution and ecological degradation;
#promote conservation; and
#secure ecologically sustainable development and use of natural resources while promoting justifiable economic and social development.

Sustainable development and the protection of the environment is, therefore, a constitutional obligation and there is a requirement for ‘reasonable legislative and other measures’ to be put in place to ensure that this achieved. '''This document represents a measure taken by the Department of Health to achieve sustainable development.'''

===Carbon emission mitigation strategies===
South Africa is a signatory to both the United Nations Framework Convention on Climate Change (UNFCC) and the Kyoto Protocol. In order to address UNFCC commitments, the Long Term Mitigation Scenarios (LTMS) process was initiated in 2006 and completed in 2008. This formulated strategies to ensure that South Africa would reduce carbon emissions. Many of the mitigation strategies identified have implications on the built environment and these are outlined below (DEAT 2009b):

*Limits on less efficient vehicles

*Passenger modal shift
*Solar water heater subsidy

*Commercial efficiency
*Residential efficiency

*Renewables with learning

*Waste management

*Land use: afforestation

*Escalating CO2 tax

Following the LTMS process, key policy approaches were agreed on by the South African cabinet. These strengthen current energy efficiency and demand-side management initiatives such as environmental fiscal reform and carbon taxation which will penalize energy inefficient technology and provide for additional tax allowances of up to 15% for energy-efficient equipment.
The LTMS process however also showed that although significant emission reductions could be achieved through technology-based actions, these were not sufficient for the scale of change required and that adaptations in social behaviour would be required. (DEAT 2009c).The LTMS, therefore, proposed a number of people and building orientated measures that offered low-cost large scale mitigation impacts including:

*Social adaptation and changes in human habitation, urban planning and the built environmental

*Studies on the distance between work, home and other life functions

*Modal shifts to public transport and moves away from individual car owners towards the operation of shared vehicles

*Food production and consumption, as well as the localization of these activities

==Built environment sustainable development objectives==
The environmental context, legislation and potential future measures to reduce carbon measures make it clear that the built environment must change to support sustainable development. It also makes it clear that many of the conventional practices in the planning, design, construction and management of building must be substituted with improved more sustainable approaches.
In order to develop practical measures that can be integrated into the built environment, it is useful to set out built environment or development objectives that, together, would support sustainable development. These objectives are outlined below and form the starting point for the next sections of this document where more detailed criteria are provided.

===Environmental objectives===

*Energy: The building is energy efficient and uses renewable energy

*Water: The building minimises the consumption of mains potable water.

*Waste: The building minimizes emissions and waste directed to landfill

*Materials: Construction impacts of building are minimized
*Biodiversity: The building supports biodiversity

===Economic objectives===

*Transport: The building supports energy efficient transportation
*Resource Use: The building makes efficient use of resources
*Management: The building is managed to support sustainability
*Local Economy: The building supports the local economy
*Products and Services: The building supports use of more sustainable products and services

===Social objectives===

*Access: The building supports access to facilities

*Health: The building supports a healthy and productive environment

*Education: The building supports education
*Inclusion: The building is inclusive of diversity in population

*Social Cohesion: The building supports social cohesion

===Integrating sustainable development objectives into health facilities===
Integrating sustainable development objectives requires structured processes. These are described below in terms of design and operational processes.

===Design processes===
Addressing sustainability in designs for new health facilities can be achieved through the following steps:

'''Target setting:''' Challenging sustainability targets should be set for the building and agreed with all of the key stakeholders of the project including the design team, the facilities manager and the funder or owner of the building. Targets should take into account government policy and strategies as well as local and international best practice.

2. '''Design principles:''' Strategies and design principles required to achieve these sustainability objectives should be understood and established from the outset. For instance, energy targets may require passive environmental control strategies to be well understood and established from the outset. These strategies and their implications can be understood through analysis of best practice examples and precedents.

3. '''Integrated design:''' Once targets and design principles have been established, an integrated design process should be used to ensure that all aspects of the building work together to achieve the required performance. This requires the different disciplines to work closely together.

4. '''Testing:''' Throughout the design process, checks should be carried out to ensure that targets set will be achieved. This can be done through calculations, modelling and analysis which assesses performance against targets set. Where aspects of the design are found not to meet targets a re-evaluation of the design should be carried out and in an iterative and integrated way, improved, to ensure that performance achieves, or surpasses, targets set.

5. '''Detailed design and implementation:''' It is important to ensure that the principles set out in 2 above, are carried out in to detail otherwise this may affect operational performance. This includes, for instance, details such as appropriate locations for switches, labels and instructions.

6. '''Handover:''' On completion, effective processes should be followed to ensure that design intentions are carried through into building operation. This includes effective commissioning, handover and training processes which ensure that designers, subcontractors and suppliers transfer knowledge and skills to facilities managers required to ensure effective management of the building.

===Operational performance===
Addressing sustainability in existing or newly developed health facilities can be achieved through the following steps:

#'''Data''': Obtain operational performance data on your building for at least a full year. For energy, this can be obtained in the form of utility statements that indicate energy consumption in kWh.
#'''Benchmark''': The above data should be normalised so that it can be compared to benchmarks. This will indicate whether your facility is below or above benchmark performance. If performance is well over benchmark, further investigation should be carried out, as this indicates there is room for improvement.
#'''Walkthrough assessment''': A walkthrough energy assessment can be used to identify where obvious improvements can be made. Checklists are used as a basis for these assessment and they can be carried out by health facilities personnel with training or experience of the respective areas such as water and energy.
#'''Audit''': Where walkthrough assessments and benchmarking exercise indicate that a full audit is warranted this can be carried out. These audits provide detailed reports on interventions that can be carried out to improve sustainability performance in a facility.
#'''On-going operational performance''': A key component of improving sustainability operational performance, in combination with the steps above, is an on-going programme that improves performance. This includes detailed sustainability monitoring and reporting as well as day-to-day management processes required to optimise performance. Operational performance should be allocated to an individual who is required to report on this to senior management. Identified responsible persons should be provided with appropriate training, resources and incentives to achieve excellent energy performance.

==='''Sustainability integration plans'''===
The above processes can be supported through sustainability integration plans which present targets, strategies and monitoring process for each sustainability performance areas. The simplest form of this is illustrated in the table below and can be used for both design and operational processes.

Area Targets Strategy Monitoring
Sustainability performance area Sustainability targets and requirements Proposed strategy and processes Progress on achievement of targets
{| class="wikitable"
|+
!Area
!Targets
!Strategy
!Monitoring
|-
|Sustainability performance area
|Sustainability targets and requirements
|Proposed strategy and processes
|Progress on achievement of targets
|-
|
|
|
|
|-
|
|
|
|
|}



==ENERGY==

===Objective===
The building is energy efficient and uses renewable energy

===Introduction===
Energy is used in health facilities to operate equipment, heat water, and to ensure that required minimum lighting, ventilation and thermal comfort standards are met. In most existing South African building it is estimated that savings of up to 30% of energy consumption can be achieved at no or low cost. These savings can be considerably higher in new facilities were passive strategies, energy efficient equipment and renewable energy systems can be used.

Ensuring that health facilities are more energy efficient use renewable energy has a wide range of benefits including:

*Reduced carbon emissions and therefore global warming impacts

*Reduced impact of mains power outages

*Reduced negative health impacts of pollution from coal-fired power stations

*Reduced operational costs

*Improved internal environment where passive strategies such as day lighting and natural ventilation lead to improved internal conditions relative to mechanical ventilation and artificial lighting.

===Energy consumption in health facilities===
Energy in South African health facilities is largely sourced from electricity, however gas and coal may also be used in larger hospitals and some rural clinics rely on local renewable energy systems such as photovoltaic panels and solar water heaters. The proportions of energy use in a conventional South African hospital and clinic are shown in the pie charts below:
{| class="wikitable"
|+
!
!
|-
|Proportions of energy consumption in a typical South African hospital
|Proportions of energy consumption in a typical South African clinic
|}

Data on energy consumption and demand in South African facilities is not readily available. However the following table provides a number of benchmarks 1
{| class="wikitable"
|+
!Energy benchmark type
!Typical
!Good practice
|-
|Clinics
|
|
|-
|Energy consumption (kWh/m2.a)
|1
|1
|-
|Maximum demand (VA/m2)
|1
|
|-
|Renewable energy (kWh/m2.a)
|0
|
|-
|Hospitals
|
|
|-
|Energy consumption (kWh/m2.a)
|395 2
|1
|-
|Maximum demand (VA/m2)
|1
|
|-
|Renewable energy (kWh/m2.a)
|0
|
|}
 
===Design Criteria===
Highly energy efficient facilities are optimized and integrated solutions that respond closely to the local site, climate and required internal functions. It is therefore difficult to prescribe this in a set of specific design criteria; however a series of questions are outlined below which can be used to check that key energy considerations have been addressed.

===Design and operation===
Improving energy performance in health facilities requires plans, procedures and processes that ensure that sustainability is integrated effectively into design and operations of a health facility. This can be achieved through setting challenging targets and effective monitoring processes.

#Have challenging sustainability targets been set for energy?
#Have effective procedures been established to model and test performance throughout the design process to ensure that these targets are achieved?
#Have the effective monitoring and evaluation systems, including regular reporting to the client, been put in place to ensure targets are achieved?
#Have capacity and systems in the form of staffing, training, manuals, commissioning and monitoring processes been planned for and put in place to ensure that design targets are achieved in operation.

===Orientation===
Orienting facilities so that the long facades face North – South helps to reduce unwanted heat gains from low angle sunlight early in the morning and late in afternoon. Where there is no alternative but to have facades face East and West, appropriate solar shading should be provided to avoid glare and control solar heat gain.

1. Are the long facades of facilities orientated to face within 15 degrees of a North – South orientation?

2. Is glazing on West and East facades minimized?

===Building shape===
While building shape and form may generally be determined by the functions accommodated, building form can also be shaped to minimise energy consumption. Shaping built form to limit building depth (see below) ensures that interior spaces can be naturally ventilated and day lit. Built form can also direct prevailing breezes through the facilities, supporting cooling and ventilation. It can also be used to create comfortable external spaces.

#Does the form of the building respond to local climate and topography?
#Does the building shape support reduced energy consumption and help create comfortable internal and external spaces?

===Building depth===
Limiting building depth enables internal space to be day lit and naturally ventilated. This ensures that internal space may not need artificial lighting or mechanical ventilation for much of the day, reducing energy consumption.

#Are building depths less than 15m?

==='''Insulation'''===
Insulation, especially when combined with thermal mass can be used to maintain comfortable indoor conditions without significant use of mechanical equipment. Insulation can ensure that valuable heat gains from people, equipment and the sun can be retained in the building to support comfort during winter. It can also reduce unwanted heat gains from ambient conditions in summer.

#Do the building envelope U-values achieve or surpass minimum values outlined in SANS 204 (SABS 2008)?

==='''Solar shading and glazing'''===
Glazing is usually the most vulnerable area of a building envelope and high heat losses and gains can be experienced through this component. It is therefore important to design glazing and devices which enable light and heat flow to be controlled.

#Is the glazing to wall ratio compliant with SANS 204 (SABS 2008)?
#Is solar shading compliant with SANS 204 (SABS 2008)?
#Has glazing with appropriate U-values, visual transmittance and solar heat gain coefficients been selected?

===Opening areas===
Opening areas within the building envelope such as doors and windows can be used to naturally ventilate the building. In general, it is advisable to provide for openings even in facilities that are mechanically ventilated and cooled as this enables them to be occupied and used in the event of a power cut.

#Are opening areas located to support effective natural ventilation?
#Is the area of openings provided compliant with SANS 10400 XA:2011?

Air tightness

Uncontrolled infiltration and airflow through the building envelope can affect comfort and increase heating and cooling loads in the building.

#Has careful detailing and specification been used to minimise infiltration in the building.
#Has a plan for rigorous construction supervision been put in place to ensure that building envelopes are air tight?

===Mechanical systems===
As far as possible mechanical cooling, heating and ventilation should be avoided. If this is not possible, a mixed mode operation should be selected. Mixed mode operation use mechanical system when ambient and internal conditions require this, but otherwise rely on passive systems to maintain thermal comfort and meet ventilation rate requirements. In particular circumstances mechanical cooling, heating and ventilation may be required for much of the year.

#Can the building or most of the spaces be passively cooled, heated and ventilated without the requirement for mechanical systems?
#If the application of passive systems will not achieve an acceptable number of annual comfort hours, can complementary mechanical systems be introduced to meet the comfort and ventilation requirements?
#Where zones exist within a facility that are not tolerant of passive ventilation and comfort systems, can a zoned mixed mode ventilation strategy be adopted?
#Where mechanical systems have been used has a rigorous exercise been undertaken to identify the most appropriate and energy efficient system?
#Where mechanical systems have been used do these include features that help reduce energy consumption such as:

a. An economy cycle

b. Controls that enable easy systems adjustments in order to benefit for seasonal and occupancy changes.

===Equipment===
As equipment used in building can consume large amounts of energy, the energy efficiency of equipment and energy ratings should be a key consideration. In addition, controls that ensure equipment is switched off when not in use should be specified.

#Is energy efficiency a key consideration in the selection of equipment?
#Is benchmarking energy consumption or energy rating used to support the selection of equipment?
#Are the controls provided for equipment easy to use and do they ensure that equipment is off when not required?

===Internal lighting===
Ensuring adequate lighting levels may be a key consideration in many spaces within health building. This should however be achieved in the most energy efficient way. Lighting is rapidly becoming more energy efficient and there are increasingly sophisticated controls.

#Is energy efficiency a key consideration in the selection of lighting?
#Has a rigorous evaluation process, including lighting power density calculations, been undertaken to ensure that the selected lighting system is highly energy efficient?
#Have appropriately sized lighting zones (ie under 100m2) been designed to avoid lighting being on where it is not required.
#Are lighting switching arrangements easy to use and encourage users to switch off lighting when not required?
#Are motion sensors used to switch lighting off in areas such as store rooms and meeting rooms when these are not used?
#Are daylight sensors used to switch lighting off in areas where these is adequate daylight? Areas with good daylight are usually found within a zone of about 6 m from external windows.
#Can light harvesting techniques and systems be incorporated in the design solution?

===External lighting===
Concerns about security often result in highly lit external areas. While security and building access requirements must be met, external lighting should be designed to be as energy efficient as possible.

#Are only areas that specifically require external lighting included?
#Has external lighting been provided as close to the area that requires lighting as possible and directed in order to avoid losses and light pollution?
#Are photo sensors, motion sensors or timers used to ensure that lighting is only on when required?

===BMS system===
Building Management Systems (BMS) should be used in complex building with complex equipment and systems. A BMS enables different systems to integrated and controlled and can support energy efficiency

#Has a BMS been used to coordinate and integrate systems, where complex systems are used in a large building?
#Is the BMS easy to use and understand?
#Is there local training and support for the BMS>
#Is the BMS system developed to open protocols and standards?
#Does the BMS include features that support energy efficiency such as:

a. Easy access to equipment schedules so that these can easily be changed to suite occupancy patterns.

b. Reminders to ensure that BMS operator tune building systems for greatest energy efficiency. For instance the system may provide a reminder to change air conditioning set points to match seasonal changes.

c. Reporting on water and energy sub metering and related equipment schedules.

===Sub metering===
An appropriate sub-metering system enables effective energy management. A facilities manager can see how much energy is used in different areas or uses in the facility. Sub-meters also show when and how energy is used through for instance energy profiles which show energy consumption and demand over time.

#Has an energy sub metering design been developed that will monitor all of the main energy uses in the facility?
#Is energy management data provided in formats and reports that can be easily understood and analyzed to support improved energy management?
#Does the system provide energy management report that can be used by both facilities managers and senior managers to improve energy efficiency in the facility?

===Renewable energy===
Increasingly renewable energy is becoming a competitive alterative to ESKOM supplied power. It also has the advantage that it increases the energy autonomy and independence of facilities, allowing these to operate even when there are mains power cuts.

#Are solar water heaters used to heat water in the facility?
#In areas with high quality, reliable sunlight, are photovoltaic systems used to reduce the reliance on ESKOM power?
#In areas with high quality, reliable wind, are wind turbines used to supplement to reduce the reliance on ESKOM power?

==WATER==

===Objective===
The building minimises the consumption of mains potable water.

===Introduction===
Water is used in health facilities for cleaning equipment, utensils and facilities, laundry, irrigation, food preparation and for drinking. In most existing South African health facility it is possible to reduce mains potable water consumption at no or low cost. These savings can be considerably higher in new facilities where water efficient technologies, grey water and rainwater systems can be used.

Ensuring that health facilities are more water efficient has a wide range of benefits including:

*Reduced water consumption and associated negative environmental impacts
*Reduced impact of mains water shortages or outages
*Reduced operational costs

===Water consumption in health facilities===
Water in South African health facilities is largely sourced from municipal potable water supply, however in some areas water may come from a rain water tanks or a borehole. The proportions of water use in a conventional South African hospital and clinic are shown in the pie charts below:
{| class="wikitable"
|+
!
!
|-
|Proportions of water consumption in a typical South African hospital
|Proportions of water consumption in a typical South African clinic
|}



Data on energy consumption and demand in South African facilities is not readily available. However the following table provides a number of benchmarks 1
{| class="wikitable"
|+
!Water benchmark type
!Typical
!Good practice
|-
|Clinics
|
|
|-
|Water consumption (kl/m2.a)
|1
|1
|-
|Hospitals
|
|
|-
|Water consumption (kl/m2.a)
|70 2
|1
|}
 

===Criteria===
The consumption of mains potable water in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective performance requirements within the health facility; however a series of questions can be used to check that key water considerations have been addressed. These are outlined below.

===Wash Hand Basin Taps===
Controlling and reducing water flows in wash hand basin taps can be used to reduce water consumption.

#Are wash-hand basin tap flow rates should not exceed 6L/minutes?
#Are passive infra-red (PIRs) or push-button controls used to limit the duration of flows?
#Has legionella control been considered when designing for low flow and systems and where existing system are made redundant?

===Toilets===
Reducing flush rates in water-borne sanitation can be used to reduce water consumption.

#Have WC flush rates been specified that do not exceed 6L/flush?
#Have dual flush controls can be used to ensure that reduced flush rates can be used when full flushes are not required?

===Showerheads===
Controlling and reducing water flows in showers can be used to reduce water consumption. The following measures can be considered:

#Have shower head flow rates been specified to not exceed 10L/minute?
#Are push-button type controls used to limit the duration of flows?
#Has legionella control been considered when designing for low flow and systems and where existing system are made redundant?

===Irrigation===
Minimizing irrigation water requirements can be used to reduce water consumption. The following measures can be considered:

#Are locally indigenous species (species found in the local area) used to minimise irrigation requirements?
#If irrigation is required, are highly efficient water delivery systems, such as a drip irrigation linked to soil moisture probes, used to minimise irrigation requirements.
#Has grey water been used to avoid the use of potable water for irrigation?

===Grey water systems===
Grey water systems reduce mains potable water consumption by reusing lower quality water within the facility. Examples of this are where waste water from showers and wash hand basins is captured and reused to flush toilets. Other sources of grey water include waste water from laundries and HVAC systems. Grey water systems however are potentially hazardous to human health, particularly in health facility environments. In particular, grey water which is left to stand for over 36 hours or is contaminated by food or similar waste is considered as blackwater and requires the same treatment as sewage. Therefore, grey water systems should only be designed, implemented and operated by appropriately competent people. Potential grey water applications in health facility environments are described below:

*Wash hand basin and shower waste water: Waste water from wash hand basins and showers can be directed to a grey water system and then used to flush toilets or for landscape irrigation.
*Vehicle wash: Waste water from vehicle waste can be reused to wash vehicles for up to 3 or 4 times. After this it can be disposed of or used for irrigation.
*HVAC plant: It may be possible to use waste water from HVAC systems for irrigation or to flush toilets. To ascertain if this is possible investigations should be carried out with the HVAC manufacturer and grey water specialists.

The following considerations in relation to grey water systems should be made:

*Have significant sources of grey water from, for instance, showers and wash-hand basins, been captured in a grey water system?
*Are grey water usage points appropriately labelled to prevent unsafe consumption.
*Will this grey water be used for irrigation or to flush toilets in order to significantly reduce portable water consumption?
*Is the proposed grey water system easy and cost effective to maintain?
*Have as many of the potential health hazards associated with the system been eliminated?

===Rain water systems===
Rain water systems store water captured from roofs or hard landscape surfaces. This water is then available for irrigation, to flush toilets or for cleaning. In large facilities very substantial amounts of water can be captured and used to reduce mains potable water consumption. A number of different types of systems are described below:

*Roof rainwater harvesting: Rainwater from roofs is directed to tanks and stores. Usually a proportion of initial run-off is directed to waste as it may have picked up dust and other debris. This system is the most common and generally has the lowest cost as rainwater tanks can be installed above ground surface.
*Hard surface rain water: This system captures storm water run-off from hard surfaces such as game pitches, paths and car parking. This type of system generally requires some form of filtration to remove debris, and in the case of car parking, oil wastes. Tanks are usually sub-surface.
*Landscape surface run-off capture: Surface run-off from soft landscaping can be captured and reused. This is sometimes used as part of an onsite storm water retention strategy. The disadvantage of this system is that the resulting water quality can be poor as debris and silt may be picked up. The filtration and maintenance requirements are therefore more stringent.

The following considerations in relation to rain water systems should be made:

#Have significant sources of rain water from roof and hard surfaces been captured in a rainwater harvesting system?
#Will this rain water be used in functions such as irrigation or to flush toilets in order to significantly reduce portable water consumption?
#Is the proposed rainwater harvesting system easy and cost effective to maintain? Have as many of the potential health hazards associated with the system been eliminated?

==WASTE==

===Objective===
The building minimizes waste directed to landfills.

===Introduction===
Waste in South African health facilities is largely directed to landfill sites. Not only does this use up valuable land, but can also lead to air, soil and water pollution if not waste is not disposed of correctly. In addition, this waste also consists of valuable resources that could be easily reused and recycled. Recycling and reusing materials not only reduces energy and resource consumption but can also create jobs and additional revenue streams.

Ensuring that health facilities minimise waste and reuse and recycle waste products are as follows:

#Reduced loss of land area to landfill
#Reduced energy and resource consumption
#Potential to create jobs and small enterprises

===Waste production in health facilities===
Waste in South African health facilities is largely directed to landfill sites. However in some area waste may be disposed of by local recyclers. The proportions of waste generated use in a conventional South African hospital and clinic are shown in the pie charts below:
{| class="wikitable"
|+
!
!
|-
|Proportions of waste in a typical South African hospital
|Proportions of waste in a typical South African clinic
|}

Data on waste in South African facilities is not readily available. However the following table provides a number of benchmarks 1
{| class="wikitable"
|+
!Waste benchmark type
!Typical
!Good practice
|-
|Clinics
|
|
|-
|Waste production (kg/m2.a)
|1
|1
|-
|Proportion of waste recycled or reused
|10%
|
|-
|Hospitals
|
|
|-
|Waste production (kg/m2.a)
|1
|1
|-
|Proportion of waste recycled or reused
|10%
|
|}

===Criteria===
Waste in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that key waste considerations have been addressed. These are outlined below.

===Provision for recycling===
Recycling can be encouraged by developing systems that make this easy. This includes providing easy-to-use receptacles for different types of waste and providing space in the right locations so that waste can be stockpiled into worthwhile quantities for a recycler to collect.

#Are there appropriate waste receptacles at the waste source to enable waste to be disposed of easily?
#Are there adequate number and type of waste receptacles at source to ensure that the value of waste is not reduced as a result of wastage or mixing of waste? For instance, clean waste paper can be spoilt if mixed with food waste.
#Has adequate storage space been provided in an appropriate location for the different recycling waste streams so that this waste can be stockpiled and easily accessed recycling contractors?

===Engagement with local recyclers===
Engaging with local recyclers earlier in the development of a new or refurbished facility can be used to understand the recycling process and the key requirements to make this effective.

#Have all the potential waste streams been identified? These include paper, cardboard, tin, glass, plastic, timber, electrical appliances etc?
#Have appropriate associations and local recyclers related to each of these waste streams been engaged with a view to ensuring that appropriate provision and systems are put in place to maximised recycling.

===Engagement with suppliers===
Engaging with suppliers can be used to reduce waste and transportation impacts. Waste and transportation impacts can be reduced through reduced use of packaging, use of reusable containers and optimized logistic supply chains.

#Have all suppliers of substantial goods and services to the health facilities been identified? Have these been engaged in relation to transportation and packaging with a view to minimising impacts in these areas?
#Has provision been made to reduce packaging waste and transport impacts through aspects such as increased space allowances for releasable containers and storage of products?

===Construction waste===
Construction is a major source of landfill waste. Waste from construction however can usually be easily reduced through explicit planning and monitoring processes.

#Has was construction waste minimization and recycling been included as specific requirement within tender and contract documents?
#Has the contractor been asked to develop a construction waste management plan in order to minimise waste? Does this plan include specific construction waste management targets ie 50% of all waste on site will be recycled? Have the parties responsible for implementing the plan been identified clearly and have they been given the mandate and resources to implement the plan? Has an appropriate monitoring and evaluation systems been put in place to ensure targets are achieved?

==MATERIALS==

===Objective===
Construction impacts of building are minimized

===Introduction===
Materials used in new facilities and the refurbishment of facilities can have significant impacts. Materials may be mined, processed, manufactured and transported before being incorporated in facilities. The extent and nature of the impacts of these stages varies widely depending on the material. The selection of materials and products to be used in facilities therefore is important in reducing negative environmental impacts.

Careful selection of construction materials used in health facilities has the following benefits:

*Reduced land and mining impacts
*Reduced environmental and health impacts from manufacturing processes
*Reduced transportation impacts
*Reduced material use
*Increased use of local sustainable materials

===Material use in health facilities===
Materials are used to construct South African health facilities and largely found in the building structure and envelope. More specialist materials and products such as refrigerants are found in equipment and systems within the building. The source and processes associated with construction materials and products have a wide range of impacts. It is therefore important to understand and confirm these with respective suppliers in order to select and specify materials and components with the least negative impacts.

===Criteria===
Material and component selection in health facilities can be addressed developing criteria list, communicating this to suppliers, and using this as a basis for specification and design. The nature of these criteria will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that key material and component considerations have been addressed. These are outlined below.

===Building reuse===
Using existing facilities instead of building new avoids or reduces the requirements for construction materials and therefore the impacts associated with extracting, manufacturing and transporting these. In addition, existing facilities are usually part of the urban fabric and already serviced with electricity, water, roads and public transport. Increasing the intensity of use of this fabric increases its efficiency and avoids the requirement to replicate this elsewhere. Therefore, in most circumstances it is preferable to reuse and refurbish existing facilities rather than build new facilities.

#Can the existing facilities continue to be used? If necessary, can these be refurbished and expanded rather than building a new facility?
#Are there other existing facilities that can be used? Can these be readily adapted for health use rather than constructing new facilities?

===Contribution to Global Warming===
Construction materials can contribute to global warming through carbon emissions associated with large amounts of energy used in their extraction, processing and transportation. This is referred to as embodied energy. Other materials such as refrigerant can contribute directly to global warming if they are released or leak into the atmosphere. Using existing facilities instead of building new avoids or reduces the requirements for construction materials and therefore the impacts associated with extracting, manufacturing and transporting these. In addition, existing facilities are usually part of the urban fabric and already serviced with electricity, water, roads and public transport. Increasing the intensity of use of this fabric increases its efficiency and avoids the requirement to replicate this elsewhere. Therefore, in most circumstances it is preferable to reuse and refurbish existing facilities rather than build new facilities.

#Refrigerants: Where refrigerants are being used in HVAC systems, cold rooms or in fire suppressions sytems have refrigerants with the lowest Global Warming Potential (GWP) and Ozone Depleting Potential (ODP) impacts been selected?
#High embodied energy materials: As far as possible, have construction materials with low embodied energy such as timber been selected? Where it is not possible to use these type of materials and high embodied energy materials such as cement and aluminium have to be use have the quantities of these materials been minimised?

===Reused materials or materials with recycled content===
Construction materials that are reused or have recycled content have less energy associated with their manufacture than equivalent new materials. Where possible, it is therefore preferable to reuse materials that may have already been used in another building or to select materials with recycled content.

#Are there materials from another building that is being demolished that could be reused? Aspects that can be reused include structure steel elements, facades, demountable structures such as carports, and building components such as windows and doors. Crushed concrete from demolished structures can also be used as aggregate in new construction.
#Have materials with recycled content been specified in preference to materials without any recycled content? Can the supplier / manufacture confirm the reduced environmental impacts of their recycled content product relative to new products?

===Reduced material use===
The quantity of construction materials used in facilities can be reduced through avoiding material use, using materials more intelligently and using materials for more than one use.

#Avoided material use: Have materials been avoided where these are not required? For instance, can ceilings and plastering be avoided through better concrete finishes? Can improved floor finishes be used to avoid the requirement for carpets and tiling? Can the use of passive systems reduce the requirement for ducting and plant?
#Intelligent material use: Can quantities of materials be reduced through different designs and specifications? For instance, can structural strategies such as pre-tensioning concrete slabs and waffle slabs be used to reduce concrete requirements? Can material use and wastage be reduced through use of precast elements?
#Dual plus use: Can materials be used for more than one purpose? For instance, can photovoltaic panels be used as a roofing material as well as to generate material?

===Material source===
The quantity of construction materials used in facilities can be reduced through avoiding material use, using materials more intelligently and using materials for more than one use.

#Avoided material use: Have materials been avoided where these are not required? For instance, can ceilings and plastering be avoided through better concrete finishes? Can improved floor finishes be used to avoid the requirement for carpets and tiling? Can the use of passive systems reduce the requirement for ducting and plant?
#Intelligent material use: Can quantities of materials be reduced through different designs and specifications? For instance, can structural strategies such as pre-tensioning concrete slabs and waffle slabs be used to reduce concrete requirements? Can material use and wastage be reduced through use of precast elements?
#Dual plus use: Can materials be used for more than one purpose? For instance, can photovoltaic panels be used as a roofing material as well as to generate material?

===Sustainable sources===
Materials can be defined in terms of whether they are from sustainable or non-sustainable sources. Materials from sustainable sources include timber, cork, wool that are grown and therefore can be harvested on an on-going materials. Other materials such as plastics and metals are mined and therefore once these sources are depleted will not be available.

#Where possible, have materials from sustainable sources been specified? For example, have timber, and plant-based products been used in preference to materials that have to be mined and processed?
#Are materials from sustainable sources actually being grown and harvested on a sustainable on-going basis? For instance, has timber specified been certified by the Forest Stewardship Council (FSC) as being from a sustainable source? It is important to note that there are still timber products available, in particular hardwoods, that are harvested from tropical rainforests which are not being replanted and therefore are not considered sustainable sources.

===BIODIVERSITY===

===Objective===
The building supports biodiversity

===Introduction===
Biodiversity plays a very important role for man through providing ecosystem services. Ecosystem services include the production of food and water, the control of climate and disease, supporting nutrient cycles and crop pollination and spiritual and recreational benefits.

Ensuring that health facilities take into account biodiversity has a wide range of benefits including:

*Maintaining local ecosystem services
*Providing an natural amenity such as gardens which would could support recuperation.

===Biodiversity in health facilities===
Health facilities affect biodiversity through their location and in the way that site planning and landscaping is carried out. New facilities can minimise negative impacts on biodiversity by avoiding green field sites and building outside municipal boundaries. Biodiversity within health facility sites can be supported through considered site planning and landscaping strategies.

===Criteria===
Biodiversity in health facilities can be addressed in a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key biodiversity considerations have been addressed. These are outlined below.

===Site location===
Biodiversity is being lost at a rapid rate through urban sprawl. Preserving existing biodiversity can therefore be achieved by avoiding green field site and building only within urban boundaries.

#Has the health facility been planned for a brown field (already built-on) sites?
#Has the health facility been planned for a location within an urban boundary so that this does not take up land that supports agriculture and or biodiversity.

===Design for biodiversity===
Biodiversity can be supported through site layouts and landscaping that retains existing biodiversity and enhances this.

#Has planning of the health facility ensured that existing valuable biodiversity on site is preserved?
#Have valuable links and wildlife corridors between biodiversity on the health facility and adjacent sites been preserved?
#Has the landscaping strategy enhanced existing biodiversity? Does this include the introduction of appropriate loc

==TRANSPORT==

===Objective===
The building supports energy efficient transportation

===Introduction===
Ensuring that health facilities support energy efficient transportation has a wide range of benefits including:

*Reduced air pollution and noise from vehicles
*Health benefits from increased opportunities for exercise
*More affordable transport for health facility users
*Reduced space requirements as a result of reduced parking and road requirements.

===Transportation in health facilities===
Transportation is important in health facilities as large numbers of people and goods need access to these facilities everyday. This includes health facilities staff who commute and health facilities users. The right location and provision of facilities help ensure that the transport impacts associated with this access is minimized and potential health benefits such as exercise are supported.

===Criteria===
The transportation in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that transportation considerations have been addressed. These are outlined below.

===Access to public transport===
Locating health facilities near public transport facilities and enabling good access to these encourage people to use these in preference to personal vehicles. The use of public transport can be encouraged by ensuring that health facilities are located near well used public transport nodes and that there are good walking routes between these and key locations within the health facility.

#Is the health facilities located near good public transport nodes such as minibuses, buses, trains and bus rapid transport systems?
#Are there safe, direct and easy-to-use routes between public transport nodes and key locations within the health facility? (see also provision for walking criteria)

===Provision for walking===
Making provision that encourages walking helps to ensure that people walk to health facilities instead of using vehicles. Walking can be encouraged through safe, direct and easy-to-use routes.

#Are there safe direct pedestrian routes to and around the health facilities site from neighboring areas and public transport nodes? (see also criteria 4 for detail)
#Are there safe direct pedestrian routes from neighboring areas to key locations within the health facility such as the main reception? (see also criteria 4 for detail)
#Are there safe direct pedestrian routes within the health facilities between all locations within the health facility? (see also criteria 4 for detail)
#Does pedestrian provision include safe road crossings such as bridges, underpasses and zebra crossings? Are routes wide enough and have appropriate finishes and other required characteristics to enable them to be easily used by people with disabilities and by predicted pedestrian numbers? Are routes safe and benefit from visual supervision by surrounding facilities and other pedestrians? Have lighting and appropriate security safety mechanisms been put in place if routes will be used at night?

===Provision for cycling===
Making provision that encourages cycling helps to ensure that people cycle to health facilities instead of using motorized vehicles. Cycling can be encouraged by providing secure cycle storage, changing or showering facilities and safe, easy-to-use local routes.

#Are there safe direct cycle routes to and around the health facilities site from neighboring areas? (see also criteria 4 for detail)
#Are there safe direct cycle routes from neighboring areas to key locations within the health facility such as the main reception? (see also criteria 4 below for detail)
#Are there safe direct cycle routes within the health facilities between all locations within the health facility? (see also criteria 4 for detail)
#Does this cycle provision include designated, separate routes and safe road crossings and junctions? Are routes wide enough and have appropriate finishes and other required characteristics to enable them to be easily used by predicted numbers of cyclists? Are routes safe and benefit from visual supervision by surrounding facilities and other cyclists? Have lighting and appropriate security safety mechanisms been put in place if routes will be used at night?

==RESOURCE USE==

===Objective===
The building makes efficient use of resources

===Introduction===
There are limited resources in the form of land, finance and raw materials to construct and maintain facilities. It is therefore important to use these resourced carefully. Benefits associated with careful resource use include:

*Avoiding waste
*Ensuring effective and efficient use of resources
*Ensuring that resources are available for other uses where these are not required

===Resource use in health facilities===
Health facilities use financial resources to enable construction and maintenance. They also consume materials and energy in their construction. Finally health facilities use land. Careful use of these resources enables waste to be avoided and these resources to be available for other uses where this is required.

===Criteria===
Resource in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that key resource considerations have been addressed. These are outlined below.

===Site density===
Detailed long term strategic plans for health facilities should be developed that take into account future projections. These should ensure that expansion or changes that are envisaged can be accommodated. However care should be taken that unnecessarily large areas are allocated for health facilities to avoid land being unused.

#Has a long term strategic site plan been developed for the health facility that addresses changes that may occur in the future, such as expansion or contraction?
#Has the over allocation of space for health facility sites been avoided?

===Occupancy density===
Robust sustainable facilities accommodate change through flexible and adaptable allocation and configuration of space. While this is important over provision of space should be avoided as this space will need to be serviced and maintained even if it is not used. Health facilities should therefore be designed to support spatial efficiency and effective use.

#Is the overall space allowance in the health facility in line or below health facilities norms, for instance, in terms of gross area per bed?
#Are the proportions of spaces use in the health facility in line with good practice health facilities design? For instance is the space allocated for circulation, support and ancillary services as a proportion of the total area in line with best practice norms?

===Food production===
Food production in the form of orchards or vegetable gardens are a productive way of using land that leads to both environmental and health benefits. Where land is available in health facility sites and there is water and appropriate capacity, food production should be encouraged and produce made available to be consumed within the health facility or by local communities.

#Has available land within the health facility site been developed for local food production?
#Has appropriate provision in the form of irrigation, fencing, organizational and capacity requirements been made to ensure that food production will be effective and sustained?

==MANAGEMENT==

===Objective===
The building is managed to support sustainability

===Introduction===
Facilities can be designed to support effective management. Systems can also be developed to ensure that facilities are effectively and efficiently used and maintained. In health facilities this is particularly important because of the stringent environmental requirements for health care and the high operating costs of the facility.

Ensuring that health facilities are effectively managed has a wide range of benefits including:

*Ensuring that operating costs are controlled and reduced
*Minimising disruption to health care as result of maintained and repairs
*Ensuring that maintenance is planned for and effective carried out

===Building management in health facilities===
Building management aims to ensure that health facilities are effectively operated and maintained in order to support healthcare services that they accommodate. Personnel with appropriate capacity, mandate and resources should be allocated to this function.

===Criteria===
Building management in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that building management considerations have been addressed. These are outlined below.

===Energy and water sub metering===
Energy and water sub metering enables the manager of a health facility to manage the consumption of energy and water and reduce costs associated with these services.

#Has energy sub metering been installed which enables energy consumption in all areas with substantial loads to be measured and monitored? Do energy meters support assessment of energy consumption trends, profiles and comparison with benchmarks?
#Has water sub metering been installed which enables water consumption in all areas with substantial consumption to be measured and monitored? Do water meters support assessment of water consumption trends, profiles and comparison with benchmarks?
#Is water and energy consumption monitored and reported to senior management on a regular basis?

===Facilities management manual===
A facilities management manual provides technical detail on all aspects of the building and how they should be maintained and managed. It is useful because it provides a repository of knowledge and information that can be used by facilities managers and their staff to ensure that health facilities are effectively managed and maintained.

#Has a detailed facilities management manual been developed for the health facilities? Does this include a detailed schedule for maintenance and other checks on equipment such as lighting, pluming fittings and HVAC
#Does the facilities management manual refer to a full set of as-built drawings and equipment manuals? Have a full set of hard copy and electronic copy as-built drawings and manuals been provided?
#Have facilities managers in the building had a full induction on the building’s systems and the facilities management manual?
#Does the facilities management manual get regularly reviewed and updated to reflect upgrade and renovations details.

===Senior management commitment===
Effective management of facilities can be supported by senior management commitment. Regular reporting on facilities performance such as energy and water consumption serve to ensure that management is aware of these issues and are likely to ensure that the appropriate mandate and resources are in place to improve this.

#Have facilities management policies in relation to sustainability been developed? For instance, are there policies or guidance on how energy and water consumption will monitored and managed?
#Have facilities management policies or guidelines been endorsed by senior management? Is there are requirement for facilities management to report on facilities performance on a regular basis to senior management?

==LOCAL ECONOMY==

===Objective===
The building supports the local economy

===Introduction===
The construction and maintenance health facilities are a significant investment by government. This investment, if considered carefully, can be used to support the local economy and employment. This is done by specifying local products and services from the local area.

Ensuring that health facilities support the local economy has a wide range of benefits including:

*Increased local employment
*Increased local capacity for new construction and maintenance of facilities

===Local economy in health facilities===
Supporting the local economy can be achieved in new facilities by understanding the nature and type of local building product suppliers and where appropriate specifying these in the building. Similarly understanding the capacity and skills of local contractors can be used to ensure that these are developed and enhanced by being engaged in the construction and maintenance of health facilities.

===Criteria===
Supporting the local economy in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key waste considerations have been addressed. These are outlined below.

===Small enterprise support===
The waste and emissions in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key waste considerations have been addressed. These are outlined below.

Minimizing irrigation water requirements can be used to reduce water consumption. The following measures can be considered:

#Are small enterprises provided with opportunities to tender for relevant construction and maintenance contracts? Can local, small enterprises be given preference in the awarding of work?
#Where local small enterprises have limited capacity and experience, can they be supported by encouraging partnerships with more established and larger enterprises?

===Material and component procurement===
The specification of local materials and components in the construction of health facilities can provide a significant incentive to local suppliers and manufacturer to develop appropriate products and capacity. This in turn provides local employment and can ensure that maintenance and repairs at the facilities can be carried out more quickly and cost effectively.

#Has a review of local materials and components been carried out?
#Have local materials and components been specified?

===Construction employment===
The construction industry can employ significant numbers of people. This can be supported through designs, specifications and labour intensive construction techniques which can be used to construct facilities without significant cost or time implications. Local construction employment improves the local economic impact of projects and ensures that there is local capacity to undertake repairs and maintenance of facilities.

#Is construction employment a key consideration in the design, specification and construction of the facility?
#Have opportunities to create local employment been sought and developed through the project?

==PRODUCTS AND SERVICES==

===Objective===
The building supports use of more sustainable products and services

===Introduction===
Products and services used in health facilities have a range of impacts and planning can be used to maximise beneficial impacts and avoid negative impacts. The construction and maintenance health facilities are a significant investment by government. This investment, if considered carefully, can be used to support the local economy and employment. This is done by specifying local products and services from the local area.

Ensuring that health facilities support the more sustainable products and services has a wide range of benefits including:

*Reduced waste
*Increased support for sustainable choices and options for health facility users

===Products and services in health facilities===
Supporting the local economy can be achieved in new facilities by understanding the nature and type of local building product suppliers and where appropriate specifying these in the building. Similarly understanding the capacity and skills of local contractors can be used to ensure that these are developed and enhanced by being engaged in the construction and maintenance of health facilities.

===Criteria===
Supporting the more sustainable products and services in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key product and service considerations have been addressed. These are outlined below.

===Local produce===
Impacts associated with transport and storage / refrigeration mean that produce imported from some distance away generally has significantly higher ecological footprints than local produce. Health facilities can therefore reduce ecological footprints associated with food through using local produce as far as possible.

#Is local produce used in preference to produce imported some distance away?
#Has the use of local produce been made a requirement in outsourced catering contracts?

===Vegetarian options===
Meat-based meals generally have significantly higher ecological food print requirements relative to vegetarian meals. Providing vegetarian options can therefore support reduced food impacts within health facilities.

#Are vegetarian options provided in catering establishments within the health facility?
#Has the provision of vegetarian options been made a requirement for outsourced catering contracts?

===Drinking water===
Waste streams can be reduced by providing alternatives to bottled drinking water. Drinking water can be provided through strategically located drinking fountains, as well as being supplied in reusable containers. A ready supply of drinking water also has health benefits.

#Is non-bottled drinking water readily and freely available throughout the health facility?

===Reuseable vessels===
Significant waste streams can be avoided through the use of reusable vessels. In particular disposable food and drink vessels can be avoided by providing reusable vessels. This option can be supported through provision of required storage and washing and facilities.

#Have reusable vessels been specified in preference to disposable containers, for services such as catering?
#Has adequate provision been made for reusable vessels in the form of storage and washing facilities?

==ACCESS==

===Objective===
The building supports access to facilities

===Introduction===
Current work patterns and lifestyles mean that many people have to access facilities such as banking, retail, childcare and communications on a regular basis. Ensuring that these facilities are within the health facility or within easy walking distance helps to avoid or reduce associated time and transport impacts.

Ensuring that health facilities support access to facilities has a wide range of benefits including:

*Reduced transport impacts
*Reduced time spent travelling to and from facilities

===Access to facilities in health facilities===
Supporting access to local facilities can be achieved through incorporating these into the health facility. Alternatively the health facility can be located near where these exist. It may also be possible to work with relevant service providers in order to provide these locally.

===Criteria===
Supporting access to facilities in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key access considerations have been addressed. These are outlined below.

===Banking===
Access to banking can be provided through formal banking facilities or through bank ATMs. This can be provided within the health facility or within easy walking distance of this.

#Are banking facilities available within the health facilities or within the local area?

===Grocery retail===
Grocery retail can be provided through local shops, supermarkets and markets. This can be provided within the health facility or within easy walking distance of this.

#Are grocery retail facilities available within the health facility or within the local area?

===Communication===
Access to telephone and internet can be provided through internet cafes or at stand alone kiosks. This can be provided within the health facility or within easy walking distance of this.

#Are internet and telephone facilities available within the health facility or in the local area?

===Café===
Access to catering facilities can be provided through cafes, restaurants or canteens. Refreshments should be affordable and accessible to both staff and health facility users. This can be provided within the health facility or within easy walking distance of this.
1. Is there an accessible, affordable café, restaurant or canteen within the health facility or in the local area?

===Childcare===
Significant waste streams can be avoided through the use of reusable vessels. In particular disposable food and drink vessels can be avoided by providing reusable vessels. This option can be supported through provision of required storage and washing and facilities.

#Is there a childcare facility within the health facility or in the local area?

==HEALTH==

===Objective===
The building supports a healthy and productive environment

===Introduction===
Health facilities by their definition aim to support health and well being in their users. In addition to medical care health can be promoted through beneficial environmental conditions including a plentiful supply of fresh air, views and optimum thermal comfort conditions. It is particularly important to avoid conditions and situations that may be harmful to human health.
Ensuring that health facilities support the health in facility users and construction workers services has a wide range of benefits including:

*Improved recovery rates for patients
*Reduced absenteeism associated with environmental conditions by health facility staff
*Reduce injury and absenteeism rates associated with dangerous or harmful working construction environments

===Criteria===
Ensuring construction and health facilities promote health can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that health promotion considerations have been addressed. These are outlined below.

===External views===
Views and a connection to the external environment improve internal environmental conditions and can help improve recovery rates and reduce employee absenteeism.

#Do health facility staff working areas have views to the external environment
#Do patient areas have views of the external environment?

===Daylight===
Day lighting can help reduce energy consumption associated with artificial lighting. It also improves internal environmental conditions for patients and health facility employees.

#Are health facility staff working areas well day lit?
#Are patient areas well day lit?

===Ventilation===
High levels of fresh air are important for human health and productivity. This can be provided through natural or mechanical ventilation. Where mechanical ventilation is used sufficiently high levels of external, fresh air should be provided and recirculated air should be avoided or minimized.

#If the condition of outside air makes it unfit for direct ventilation use, is it appropriately pre-treated and filtered by the ventilation system?
#Are health facility staff working areas well supplied with good quality outside air?
#Are patient areas well supplied with good quality outside air?

===Building materials===
Building materials can have negative impacts for human health associated with their extraction and manufacture. They may affect health in facilities, through for instance offgassing hazardous chemicals. Construction materials should therefore be screened to avoid products being used in health facilities that have negative impacts on human health.

#Has criteria been developed and applied for the selection and screening of building materials?
#Have all building materials that may off gas substances such as formaldehyde and volatiles organic components that may be harmful to human health been avoided?

===Contractor health and safety===
There are considerable health and safety risks in the construction industry. Considering health and safety in the design of health facilities can be used to reduce health and safety risks associated with construction and maintenance. Making provision for safe access to glass facades or to high level lighting helps to ensure that this can be installed, cleaned and maintained without undue health and safety risks. In addition, addressing health and safety comprehensively in contract and construction planning, procedures and processes can be used to eliminate many construction health and safety risks.

#Has contractor health and safety been considered as a key issue in the design of the building? Have construction risks been minimised through appropriate design risk assessments and mitigation?
#Have detailed construction plans, procedures and processes been developed to minimise risks where these may occur during construction?
#Has appropriate health and safety procedures been put in place to ensure that plans are implemented and monitored?

==EDUCATION==

===Objective===
The building supports education

===Introduction===
Education and on-going learning is increasingly been seen as an essential component of sustainable development and a competitive economy. This is recognised in health care through the requirement for health care professionals to under continued professional development (CPD). Education and on-going learning can be supported through technology and spaces within facilities that support this. Examples of this include training rooms and access to ICT and reading material. In addition well packaged
Ensuring that health facilities support the education has a wide range of benefits including:

*Improve ability by health facilities staff to keep up-to-date with new developments in health care
*Ability to attract and retain staff

===Criteria===
Ensuring construction and health facilities promote education and on-going learning can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that education and on-going learning considerations have been addressed. These are outlined below.

===Contractor education===
There are considerable health and safety risks in the construction industry. Considering health and safety in the design of health facilities can be used to reduce health and safety risks associated with construction and maintenance. Making provision for safe access to glass facades or to high level lighting helps to ensure that this can be installed, cleaned and maintained without undue health and safety risks. In addition, addressing health and safety comprehensively in contract and construction planning, procedures and processes can be used to eliminate many construction health and safety risks.

#Has contractor health and safety been considered as a key issue in the design of the building? Have construction risks been minimised through appropriate design risk assessments and mitigation?
#Have detailed construction plans, procedures and processes been developed to minimise risks where these may occur during construction?
#Has appropriate health and safety procedures been put in place to ensure that plans are implemented and monitored?

===Notice boards===
Notices are very easy and cost effective way of communicating information. They can be used to support education and awareness by drawing attention to new or important education. For instance, awareness and reminders about new health care policy, procedures and processes can be communicated. Notice boards have the benefit that they can be located where they will be seen by all personnel on a regular basis and are not reliant on a particular technology, such as email. This helps to ensure information can be communicated to all levels of staff within a health facility.

#Have notice boards been located in key locations in the health facility where they can be used to communicate key information to facility staff and users?
#Have communication and education plans been developed that will ensure that notice boards will be updated throughout the year with relevant notices and information?

===Space for learning===
Formal training can be supported through access to training rooms. More informal on-going learning can be provided through access to resource centres where learning material, computers and the internet can be accessed.

#Are there appropriately sized and equipped facilities to accommodate formal training?
#Are there appropriately sized and equipped facilities to support informal on-going learning by staff?

===Employee induction===
Employee induction refers to awareness training provided to new employees. This can be used to support sustainability by developing awareness in health facility staff about sustainable building systems and how they should be used. This may include aspects such as lighting and HVAC operation as well as recycling procedures.

*Have employee induction processes been developed?
*Do these include detailed information on systems in the building that aim to support sustainability?

===Building user manual===
Building user manuals aim to complement employee induction processes by providing easily accessible and understanding information related to a facility in order to support user behaviour that support sustainability.

#Has a building user manual been developed?
#Is this readily accessible and easy to use?

==INCLUSION==

===Objective===
The building is inclusive of diversity in population

===Introduction===
Design for inclusion helps to ensure that facilities can be used by all users including older people, sick people, people with children and people with disabilities. Inclusive design also often means that facilities are safer and easier to use. In health facilities both of these aspects are particularly important.

Ensuring that health facilities are inclusive has a wide range of benefits including:

*Less requirement to replicate facilities
*Facilities that are easier and safer to use

===Criteria===
Ensuring health facilities are inclusive can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key inclusion considerations have been addressed. These are outlined below.

===Accessible transport===
Inclusive access to health facilities is an important consideration. This means ensuring that people who may be ill, infirm, old or have disabilities are able to access health facilities easily. This requires accessible routes from places for work and accommodation to the facilities and often requires easily accessible local public transport systems. This can be p

Ensuring that health facilities support the education has a wide range of benefits including:

#Are there regular, affordable and efficient local transport systems?
#Can these be accessed readily from health facility users’ accommodation and places of work?
#Can the health facility be accessed readily from public transport?
#Is public transport provision inclusive?

===Environmental access===
Facility design and management for environmental access can be used to ensure that health facilities are inclusive. This requires a comprehensive approach that ensures that access consideration are effectively integrated into all aspects of health facility design. Guidance on this aspect is provided in the IUSS d

#Does the facility design fully comply with the IUSS environmental access requirements?
#Are systems and management in place to ensure that environmental access standards are maintained during operation?

===Access to affordable accommodation===
There is an increasing shortage of affordable accommodation in many South African cities. This can have a range of negative impacts including the requirement for long distance commuting, disrupted family life, and reduced family budgets for non-transport related costs such as education and health. Increasing local affordable accommodation can be achieved through partnership agreements with local developers and social housing organizations.

#Is there affordable local accommodation for health facility staff?
#If this does not exist, have initiative been taken to develop this with developers and or social housing institutions?

==SOCIAL COHESION==

===Objective===
The building supports social cohesion

===Introduction===
Social cohesion refers to the extent to which individuals within a community understand, collaborate, trust and work together. It is valuable because it enables collective knowledge and resources to be used more effectively and efficiently to support common goals. Within a health facility improved social cohesion can support improved healthcare with fewer resources by sharing and using these more effectively. It can also support improved communication and cooperation within health teams and therefore improving levels of service and reducing wastage and mistakes.

Ensuring that health facilities support social cohesion has a wide range of benefits including:

*More efficient and effective use of resources
*Improved communication and coordination
*Reduced wastage

===Criteria===
Ensuring health facilities support social cohesion can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key social cohesion considerations have been addressed. These are outlined below.

===Shared used of facilities===
Shared use of facilities helps to ensure that valuable facilities are well used and beneficial impacts are experienced across a wider range of people. Capital and operating costs of the facility may also be reduced as these are shared between a larger number of organizations or individuals. This concept can be applied to health facilities in a range of different ways. For instance, sharing arrangements with a local sport club or fitness center can be used to enable a health facility to use swimming pools and other facilities for rehabilitation without having the ongoing costs and management of this facility.

#Have shared use, and possibly development, of facilities been explored with local organizations?
#Have appropriate design considerations been put in place to ensure effective shared use of facilities?
#Have appropriate management considerations been put in place to ensure effective shared use of facilities?

===Social spaces===
Social spaces, such as canteens, cafes and common rooms can play an important role in the life of organization. They not only provide a respite from work environments they also provide a space for relaxed social interaction. This interaction and the relationships and communication networks created can may a significant impact in improving organizational effectiveness and responsiveness. In health care facilities this is a valuable resource which helps to motivate individuals and build strong teams that are able to provide effective and responsive health care.

#Have an appropriate number and type of social spaces been provided within the health facility?
#Will these facilities support easy social interaction within and between health teams, as well as cross health facility staff structures?

===Stakeholder involvement===
Involving people in decisions on issues will have an impact on them is a useful way of helping ensure that there is support for an initiative or a process. Structured involvement of stakeholder helps to ensure a shared understanding can be developed, joint decisions made and there is efficient and effective implementation. For instance, within a health facility, effective involvement of key stakeholders can help goals such as improved energy efficiency through ensuring that managers, building technical staff and health services staff understand the goal, the means that this will be achieved and can see their role in supporting this.

#Has there been appropriate stakeholder involvement in the design of health facilities?
#Has there been appropriate stakeholder involvement in the management of health facilities?

==REFERENCES==

#CIDB, 2009. South African Report on Greenhouse Gas Emission Reduction, Potentials from Facilities, A Discussion Document. Construction Industry Development Board. Page 22.
#. DEAT, 1995. Urban Open Space: Guidelines for effective management. Discussion document based on Agenda 21 and the RDP
#DEAT, 1998. National Environmental Management Act. Department of Environment and Tourism, Pretoria. Chapter 1.
#DEAT 2009, State of the Environment Report Accessible from http://soer.deat.gov.za/themes.aspx?m=387
#DEAT, 2009a, The National Climate Change Response Policy. Department of Environment and Tourism, Pretoria. Page 8.
#DEAT, 2009b, The National Climate Change Response Policy. Department of Environment and Tourism, Pretoria. Page 14
#DEAT, 2009c, The National Climate Change Response Policy. Policy Department of Environment and Tourism, Pretoria. Page 20.
#EMM and GDACE, 2007. Environmental Management Framework for Ekurhuleni. Ekurhuleni Metropolitan Municipality and Gauteng Department of Agriculture, Conservation and the Environment
#Hewitson, B. Engelbrecht, F Tadross, M. and Jack, C., 2005. General conclusions on development of plausible climate change scenarios for southern Africa, in: R. E. Schulze (ed.), Climate Change and Water Resources in Southern Africa: Studies on Scenarios, Impacts, Vulnerabilities and Adaptation, Water Research Commission, WRC Report 1430/1/05, Pretoria, South Africa.
#IPCC, 2007. Climate Change 2007, Synthesis Report. Inter Governmental Panel on Climate Change. 2007.Page 7
#SEA 2006, State of Energy in South African Cities. Sustainable Energy Africa. Cape Town.
#South African Bureau of Standards. 2007. SANS 204 Energy Efficiency in Facilities
#WWF 2006. Living Planet Report 2006.World Wildlife Fund. Accessed from www.panda.org.

==APPENDIX A: SUSTAINABILITY INTEGRATION PLANS==
 
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[[Category:Crosscutting Issues]]

Sustainability

2020-10-29T04:21:42Z

Tmojanaga: /* INTRODUCTION */

== CHAPTER 1 ==

== HISTORY ==
Legionnaires’ disease was first described after a pneumonia outbreak at an American Legion Convention held in Philadelphia during 1976. In total, 182 delegates were affected and 29 died before workers at the Centers for Disease Control and Prevention (CDC) based in Atlanta, USA isolated the causative organism in January 1977. The organism was placed in the family Legionellaceae, genus Legionella to commemorate the first victims of the disease. The first species was named Legionella pneumophila (Greek for “lung loving”).

It soon became clear that legionellae were not really new; retrospective studies showed that an organism isolated for the first time in 1944 (called Tatlockia micdadei) actually belonged to the genus Legionella. The first strain of L pneumophila was isolated already in 1947 from a guinea pig that had previously been inoculated with blood from a patient with what was called an “unknown febrile disease” at the time. The two decades following the discovery of the family Legionellaceae was marked by rapid developments in Legionella detection and the identification of numerous new species. Twenty-eight new Legionella species and two “Legionella-like amoebal pathogens” (LLAPs) (LLAP-1 and LLAP-6) were isolated during the 1980s, mostly from sources in the USA. The 1990s were marked by an increase in Legionella isolation from countries in Europe and Australia with fifteen new Legionella species being described for the first time.

More than half of the currently known Legionella species are potentially pathogenic to humans. L. pneumophila is still implicated in >80% of infections; however, as more species are isolated from environmental sources worldwide, even those species not yet associated with disease should be considered as potentially pathogenic until proven otherwise. For example, L. longbeacheae, often isolated from potting soil, is considered the most common cause of legionellosis in Australia. Legionellae are faintly staining gram negative, rod-shaped, non acid fast bacteria that to not form spores or capsules. All species except L. oakridgensis are motile. Legionellae are typically between 0.3 and 0.9 µm wide and 1- 20 µm long. However, shorter forms measuring 1- 2 µm in length are often observed in clinical specimens or under conditions of iron deprivation.

The ability of legionellae to grow in water is influenced by several factors. They can grow at temperatures between 20°C and 60°C, with optimal growth occurring between 37°C and 45°C. They prefer a pH in the range of 5.0 9.5 and only grow in the presence of Lcysteine, HCl and iron salts. Legionella-like amoebal pathogens (LLAPs) are very similar to Legionella species in that they are gram negative, infect amoebae and can survive and multiply intracellularly. However, they cannot be cultured on laboratory media. The first LLAP was isolated 1from soil in Poland in 1954 and was named Sarcobium lyticum. The next isolation of an LLAP was in England more than 20 years later. Since then, LLAPs have been isolated from various sources, mostly associated with confirmed cases or outbreaks of 2 3Legionnaires’ disease. Three of the LLAPs have since been reclassified as L. drozanskii, L. rowbothamii and L falloni. The currently known LLAPs are listed in Table 1.2.

==INTRODUCTION==

==Purpose==
This document has been developed for the Department of Health to ensure that sustainable development is integrated into to planning and design of health facilities. The document defines sustainable development and outlines the implications of this for the built environment. It provides objectives and criteria that can be used in the development health facilities in South Africa.

==Background==
The Department of Health wish to support sustainable development in South Africa and ensure that there is an appropriate balance between economic development, social integration and protection of the environment.
Global Warming and South African legislation and policy now make it imperative that built environment projects address sustainability. However, there is limited South African guidance on how sustainable development can be integrated with built environment projects. There is also the perception that addressing sustainability in facilities will be expensive and complicated.
This document provides guidance and checklists that can be used to support the integration of sustainability into health facilities. It shows that by addressing sustainability early in projects, additional costs can be minimised and innovative, high-performance solutions that benefit society, the economy and the environment can be achieved. It also shows that achieving more sustainable facilities need not be complex but can be based on robust, sensible and simple measures.

==How to use this document==

This document provides a framework that can be used to inform the development of health facilities. It can be used in the following ways:

*'''Awareness''': This document can be used to increase awareness about sustainable development and the need to address this in built environment projects. This will lead to more rigorous debate on development options and support more innovative and sustainable solutions.

*'''Setting sustainable development targets''': This framework can be used by a development team to set explicit and challenging sustainable development targets for projects. This is done by setting quantified targets against criteria in the document and putting in place systems to ensure that these are achieved.

*'''Self-assessments''': This framework can also be used for self-assessment and to ascertain the performance of development proposals. To carry this out refer to the Facility Recommended Compliance sheet and Compliance Checklist at the end of the document. This enables different health facility development proposals to be evaluated in terms of recommended compliance. Assessment using the criteria can also inform the design process by being used to evaluate different development options. This enables optimal solutions to be developed in an iterative and efficient way.

*'''Coordinated development''': Some criteria in the document may appear not to be in the remit of, or possible in, a single development. These criteria however can be achieved through partnerships and local collaboration. This framework can be used bring together the key role players in order to develop integrated plans that enable key sustainable development objectives to be achieved.

==Structure of the guideline==
The document has the following structure:

*'''Implementing Sustainable Development''': This section provides a description of sustainable development and translates this into specific sustainable development objectives for the built environment.

*'''Built Environment Sustainable Development Objectives''': In this section more detailed guidance and checklists are provided for each of sustainable development objectives listed in the section above.

*'''Sustainability Integration Plans''': This provides guidance on plans and a structure that can be used to integrated sustainability in design and operational processes.

==IMPLEMENTING SUSTAINABLE DEVELOPMENT==

===Introduction===
South Africa faces a range of social, economic and environmental challenges. HIV/AIDs has resulted in a life expectancy dropping from 67 years in 1998 years to around 47 years currently. Unemployment is estimated to be 27% and climate change is likely to lead to increasing water stress, reduced food security and loss of species and ecosystems (DEAT 2009).
Sustainable development, which aims to achieve social and economic improvements while reducing negative environmental impacts, can be used to address these challenges. Sustainable development however can be difficult to achieve. This is because a holistic and integrated approach is required and the development sector and in particular, the construction industry, operates in a highly fragmented way. In addition, the concept of sustainable development is still new and has not been adequately translated into practical actions that can be readily implemented.
This section defines sustainable development and translates this into key built environment objectives. It also describes the role of the built environment in creating environmental and other problems and shows how integrating sustainable development considerations into construction and the built environment can make a substantial contribution to improving the social, economic and environmental performance of the built environment.

===The environmental context===
Increasing carbon emissions from human activities and a reduction in the ability of the natural environment to absorb carbon dioxide is leading to an accumulation of greenhouse gases in the upper atmosphere. These gases trap more heat in the upper atmosphere leading to global warming and temperatures are predicted to increase by 2 - 6°C OC by the end of the century (IPCC, 2007). Estimates carried out for the City of Joburg indicate that temperatures in the next 50 years may increase between 2 and 3.5°C (Hewitson, Engelbrecht, Tadross, Jack, 2005).

Within Africa, South Africa produces the highest CO2 emissions and has one of the highest CO2 emissions per GDP in the world. In 2002, carbon emissions per capita in South Africa were 8.4tonnes/capita - higher than Western European averages of 7.9tonnes/capita (SEA 2006).
Global warming is likely to impact Africa particularly negatively. The National Climate Change Response Policy Developed by the Department of Environment and Tourism outlines the following impacts (DEAT 2009a):

*Agricultural production and food security in many African countries are likely to be severely compromised by climate change and variability. Projected yields in some countries may be reduced by as much as 50% in some countries by 2020 and as much as 100% by 2100. Small scale farmers will be most severely affected.

*Existing water stresses will be aggravated. About 25% o Africa’s population (about 200million people) currently experience high water stress. This is projected to increase to between 75-250 million by 2020 and 350-600 million by 2050.

*Changes in ecosystems are already being detected and the proportion of arid and semi-arid lands in Africa is likely to increase by 5-8% by 2080. It is projected that between 25 and 40% of mammal species in national parks in sub-Saharan Africa will become endangered.

*Projected sea-level rises will have implications for human health and the physical vulnerability of coastal cities. The cost of adaptation to sea level rise could amount to 5-10% of gross domestic product.

*Human health will be negatively affected by climate change and vulnerability and incidences of Malaria, Dengue fever, Meningitis and Cholera may increase.

===The contribution of the built environment===
Construction and the built environment make a substantial contribution to global warming and play a significant role most economies. Environmental, social and economic impacts attributed to the built environment at a global scale are outlined below.

*Consumes 40% of energy use,

*Consumes 17% of fresh water use,

*Consumes 25% of wood harvested,

*Consumes 40% of material use,
*Employs 10% of the world’s work force,

*Construction is the largest employer of micro-firms (less than 10 people),

*Facilities are typically located on the most productive land (Estimated to be 250 million hectares world wide, mostly on primary agricultural land).

In South Africa the built environment is directly responsible, through electricity consumption, for over 23% of South Africa’s carbon emissions (see table below). Vehicle-based infrastructure and transport planning has resulted in transport contributing to 16% of South Africa’s CO2 emissions and an additional 18mtCO2 per year, or about 4% of South Africa’s CO2 emissions, come from the manufacture of building materials (CIDB 2009).

Sector C02 Emissions

Commercial 10%

Residential 13%

Transport 16%

Industry 40%

Mining 11%

Other 10%

Total 100%

''Figure 1: South African carbon emissions per sector''

===Defining sustainability===
Recent work by the World Wildlife Fund contributes substantially to defining sustainable development by providing quantified minimum criteria for sustainability. In the 2006 Living Planet Report, sustainability is defined as achieving an Ecological Footprint (EF) of less than 1.8 global hectares per person and an Human Development Index (HDI) value of above 0.8 (WWF 2006).

===Ecological Footprint===
An Ecological Footprint is an estimate of the amount of biologically productive land and sea required to provide the resources a human population consumes and absorb the corresponding waste. These estimates are based on the consumption of resources and production of waste and emissions in the following areas:

*Food, measured in type and amount of food consumed,

*Shelter, measured in size, utilization and energy consumption,

*Mobility, measured in type of transport used and distances travelled,

*Goods, measured in type and quantity consumed.

*Services, measured in type and quantity consumed The area of biologically productive land and sea for each of these areas is calculated in global hectares (gha) and then added together to provide an overall ecological footprint. This measure is particularly useful as it enables the impact of infrastructure and lifestyles to be measured in relation to the earth’s carrying capacity of 1.8 global hectares (gha) per person.

===The Human Development Index===
The Human Development Index was developed as an alternative to economic progress indicators and aimed to provide a broader measure that defined human development as a process of enlarging people’s choices and enhancing human capabilities (United Nations Development Programme 2007). The measure is based on:

*A long healthy life, measured by life expectancy at birth,

*Knowledge, measured by the adult literacy rate and combined primary, secondary, and tertiary gross enrolment ratio,

*A decent standard of living, as measure by the GDP per capita in purchasing power parity (PPP) in terms of US dollars.

===South African EF and HDI figures===
The figures below show that South Africa has an ecological footprint of 2.1, above the maximum required of 1.8 gha and a human development index measure of 0.66, below the minimum of 0.8 required for sustainability.

Measure South Africa Sustainability Target
Ecological Footprint (gha) 2.1 1.8
Human Development Index 0.658 0.8
{| class="wikitable"
|+
!Measure
!South Africa
!Sustainability Target
|-
|Ecological Footprint (gha)
|2.1
|1.8
|-
|Human Development Index
|0.658
|0.8
|}

For South Africa to move towards sustainability there must therefore be an improvement in both the Ecological Footprint and Human Development Index performance. The built environment has a key role in supporting this improvement.

===The legislative and policy context===
South Africa has a range of legislation and policy that aims to protect the environment and support sustainable development. Key legislation supporting sustainable development includes the South African Constitution and the National Environmental Management. These are discussed briefly below.

===South African Constitution===
The South African Constitution contains a Bill of Rights that enshrines the rights of all people in South African and affirms the democratic values of human dignity, equality and freedom. The Bill has sections covering equality, human dignity, privacy, freedom of religious belief and opinion, environment, property, housing, healthcare, food, water and social security, children, education, language and culture. Through a section on equality, the Bill requires that all people have full and equal enjoyment of these rights and freedoms:

''Everyone is equal before the law and has the right to equal protection and benefit of the law.''

Equality includes the full and equal enjoyment of all rights and freedoms. To promote the achievement of equality, legislative and other measures designed to protect or advance persons or categories of persons, disadvantaged by unfair discrimination, may be taken.
Environmental rights in the Bill of Rights include the right to an environment that supports health and wellbeing. It also requires legislation to be developed to ensure that the environment is protected and that development that does occur is both sustainable, and justifiable:

===Environment===
Everyone has the right

a). to an environment that is not harmful to their health or well-being; and

b). to have the environment protected, for the benefit of present and future generations, through reasonable legislative and other measures that ¬

#prevent pollution and ecological degradation;
#promote conservation; and
#secure ecologically sustainable development and use of natural resources while promoting justifiable economic and social development.

Sustainable development and the protection of the environment is, therefore, a constitutional obligation and there is a requirement for ‘reasonable legislative and other measures’ to be put in place to ensure that this achieved. '''This document represents a measure taken by the Department of Health to achieve sustainable development.'''

===Carbon emission mitigation strategies===
South Africa is a signatory to both the United Nations Framework Convention on Climate Change (UNFCC) and the Kyoto Protocol. In order to address UNFCC commitments, the Long Term Mitigation Scenarios (LTMS) process was initiated in 2006 and completed in 2008. This formulated strategies to ensure that South Africa would reduce carbon emissions. Many of the mitigation strategies identified have implications on the built environment and these are outlined below (DEAT 2009b):

*Limits on less efficient vehicles

*Passenger modal shift
*Solar water heater subsidy

*Commercial efficiency
*Residential efficiency

*Renewables with learning

*Waste management

*Land use: afforestation

*Escalating CO2 tax

Following the LTMS process, key policy approaches were agreed on by the South African cabinet. These strengthen current energy efficiency and demand-side management initiatives such as environmental fiscal reform and carbon taxation which will penalize energy inefficient technology and provide for additional tax allowances of up to 15% for energy-efficient equipment.
The LTMS process however also showed that although significant emission reductions could be achieved through technology-based actions, these were not sufficient for the scale of change required and that adaptations in social behaviour would be required. (DEAT 2009c).The LTMS, therefore, proposed a number of people and building orientated measures that offered low-cost large scale mitigation impacts including:

*Social adaptation and changes in human habitation, urban planning and the built environmental

*Studies on the distance between work, home and other life functions

*Modal shifts to public transport and moves away from individual car owners towards the operation of shared vehicles

*Food production and consumption, as well as the localization of these activities

==Built environment sustainable development objectives==
The environmental context, legislation and potential future measures to reduce carbon measures make it clear that the built environment must change to support sustainable development. It also makes it clear that many of the conventional practices in the planning, design, construction and management of building must be substituted with improved more sustainable approaches.
In order to develop practical measures that can be integrated into the built environment, it is useful to set out built environment or development objectives that, together, would support sustainable development. These objectives are outlined below and form the starting point for the next sections of this document where more detailed criteria are provided.

===Environmental objectives===

*Energy: The building is energy efficient and uses renewable energy

*Water: The building minimises the consumption of mains potable water.

*Waste: The building minimizes emissions and waste directed to landfill

*Materials: Construction impacts of building are minimized
*Biodiversity: The building supports biodiversity

===Economic objectives===

*Transport: The building supports energy efficient transportation
*Resource Use: The building makes efficient use of resources
*Management: The building is managed to support sustainability
*Local Economy: The building supports the local economy
*Products and Services: The building supports use of more sustainable products and services

===Social objectives===

*Access: The building supports access to facilities

*Health: The building supports a healthy and productive environment

*Education: The building supports education
*Inclusion: The building is inclusive of diversity in population

*Social Cohesion: The building supports social cohesion

===Integrating sustainable development objectives into health facilities===
Integrating sustainable development objectives requires structured processes. These are described below in terms of design and operational processes.

===Design processes===
Addressing sustainability in designs for new health facilities can be achieved through the following steps:

'''Target setting:''' Challenging sustainability targets should be set for the building and agreed with all of the key stakeholders of the project including the design team, the facilities manager and the funder or owner of the building. Targets should take into account government policy and strategies as well as local and international best practice.

2. '''Design principles:''' Strategies and design principles required to achieve these sustainability objectives should be understood and established from the outset. For instance, energy targets may require passive environmental control strategies to be well understood and established from the outset. These strategies and their implications can be understood through analysis of best practice examples and precedents.

3. '''Integrated design:''' Once targets and design principles have been established, an integrated design process should be used to ensure that all aspects of the building work together to achieve the required performance. This requires the different disciplines to work closely together.

4. '''Testing:''' Throughout the design process, checks should be carried out to ensure that targets set will be achieved. This can be done through calculations, modelling and analysis which assesses performance against targets set. Where aspects of the design are found not to meet targets a re-evaluation of the design should be carried out and in an iterative and integrated way, improved, to ensure that performance achieves, or surpasses, targets set.

5. '''Detailed design and implementation:''' It is important to ensure that the principles set out in 2 above, are carried out in to detail otherwise this may affect operational performance. This includes, for instance, details such as appropriate locations for switches, labels and instructions.

6. '''Handover:''' On completion, effective processes should be followed to ensure that design intentions are carried through into building operation. This includes effective commissioning, handover and training processes which ensure that designers, subcontractors and suppliers transfer knowledge and skills to facilities managers required to ensure effective management of the building.

===Operational performance===
Addressing sustainability in existing or newly developed health facilities can be achieved through the following steps:

#'''Data''': Obtain operational performance data on your building for at least a full year. For energy, this can be obtained in the form of utility statements that indicate energy consumption in kWh.
#'''Benchmark''': The above data should be normalised so that it can be compared to benchmarks. This will indicate whether your facility is below or above benchmark performance. If performance is well over benchmark, further investigation should be carried out, as this indicates there is room for improvement.
#'''Walkthrough assessment''': A walkthrough energy assessment can be used to identify where obvious improvements can be made. Checklists are used as a basis for these assessment and they can be carried out by health facilities personnel with training or experience of the respective areas such as water and energy.
#'''Audit''': Where walkthrough assessments and benchmarking exercise indicate that a full audit is warranted this can be carried out. These audits provide detailed reports on interventions that can be carried out to improve sustainability performance in a facility.
#'''On-going operational performance''': A key component of improving sustainability operational performance, in combination with the steps above, is an on-going programme that improves performance. This includes detailed sustainability monitoring and reporting as well as day-to-day management processes required to optimise performance. Operational performance should be allocated to an individual who is required to report on this to senior management. Identified responsible persons should be provided with appropriate training, resources and incentives to achieve excellent energy performance.

==='''Sustainability integration plans'''===
The above processes can be supported through sustainability integration plans which present targets, strategies and monitoring process for each sustainability performance areas. The simplest form of this is illustrated in the table below and can be used for both design and operational processes.

Area Targets Strategy Monitoring
Sustainability performance area Sustainability targets and requirements Proposed strategy and processes Progress on achievement of targets
{| class="wikitable"
|+
!Area
!Targets
!Strategy
!Monitoring
|-
|Sustainability performance area
|Sustainability targets and requirements
|Proposed strategy and processes
|Progress on achievement of targets
|-
|
|
|
|
|-
|
|
|
|
|}



==ENERGY==

===Objective===
The building is energy efficient and uses renewable energy

===Introduction===
Energy is used in health facilities to operate equipment, heat water, and to ensure that required minimum lighting, ventilation and thermal comfort standards are met. In most existing South African building it is estimated that savings of up to 30% of energy consumption can be achieved at no or low cost. These savings can be considerably higher in new facilities were passive strategies, energy efficient equipment and renewable energy systems can be used.

Ensuring that health facilities are more energy efficient use renewable energy has a wide range of benefits including:

*Reduced carbon emissions and therefore global warming impacts

*Reduced impact of mains power outages

*Reduced negative health impacts of pollution from coal-fired power stations

*Reduced operational costs

*Improved internal environment where passive strategies such as day lighting and natural ventilation lead to improved internal conditions relative to mechanical ventilation and artificial lighting.

===Energy consumption in health facilities===
Energy in South African health facilities is largely sourced from electricity, however gas and coal may also be used in larger hospitals and some rural clinics rely on local renewable energy systems such as photovoltaic panels and solar water heaters. The proportions of energy use in a conventional South African hospital and clinic are shown in the pie charts below:
{| class="wikitable"
|+
!
!
|-
|Proportions of energy consumption in a typical South African hospital
|Proportions of energy consumption in a typical South African clinic
|}

Data on energy consumption and demand in South African facilities is not readily available. However the following table provides a number of benchmarks 1
{| class="wikitable"
|+
!Energy benchmark type
!Typical
!Good practice
|-
|Clinics
|
|
|-
|Energy consumption (kWh/m2.a)
|1
|1
|-
|Maximum demand (VA/m2)
|1
|
|-
|Renewable energy (kWh/m2.a)
|0
|
|-
|Hospitals
|
|
|-
|Energy consumption (kWh/m2.a)
|395 2
|1
|-
|Maximum demand (VA/m2)
|1
|
|-
|Renewable energy (kWh/m2.a)
|0
|
|}
 
===Design Criteria===
Highly energy efficient facilities are optimized and integrated solutions that respond closely to the local site, climate and required internal functions. It is therefore difficult to prescribe this in a set of specific design criteria; however a series of questions are outlined below which can be used to check that key energy considerations have been addressed.

===Design and operation===
Improving energy performance in health facilities requires plans, procedures and processes that ensure that sustainability is integrated effectively into design and operations of a health facility. This can be achieved through setting challenging targets and effective monitoring processes.

#Have challenging sustainability targets been set for energy?
#Have effective procedures been established to model and test performance throughout the design process to ensure that these targets are achieved?
#Have the effective monitoring and evaluation systems, including regular reporting to the client, been put in place to ensure targets are achieved?
#Have capacity and systems in the form of staffing, training, manuals, commissioning and monitoring processes been planned for and put in place to ensure that design targets are achieved in operation.

===Orientation===
Orienting facilities so that the long facades face North – South helps to reduce unwanted heat gains from low angle sunlight early in the morning and late in afternoon. Where there is no alternative but to have facades face East and West, appropriate solar shading should be provided to avoid glare and control solar heat gain.

1. Are the long facades of facilities orientated to face within 15 degrees of a North – South orientation?

2. Is glazing on West and East facades minimized?

===Building shape===
While building shape and form may generally be determined by the functions accommodated, building form can also be shaped to minimise energy consumption. Shaping built form to limit building depth (see below) ensures that interior spaces can be naturally ventilated and day lit. Built form can also direct prevailing breezes through the facilities, supporting cooling and ventilation. It can also be used to create comfortable external spaces.

#Does the form of the building respond to local climate and topography?
#Does the building shape support reduced energy consumption and help create comfortable internal and external spaces?

===Building depth===
Limiting building depth enables internal space to be day lit and naturally ventilated. This ensures that internal space may not need artificial lighting or mechanical ventilation for much of the day, reducing energy consumption.

#Are building depths less than 15m?

==='''Insulation'''===
Insulation, especially when combined with thermal mass can be used to maintain comfortable indoor conditions without significant use of mechanical equipment. Insulation can ensure that valuable heat gains from people, equipment and the sun can be retained in the building to support comfort during winter. It can also reduce unwanted heat gains from ambient conditions in summer.

#Do the building envelope U-values achieve or surpass minimum values outlined in SANS 204 (SABS 2008)?

==='''Solar shading and glazing'''===
Glazing is usually the most vulnerable area of a building envelope and high heat losses and gains can be experienced through this component. It is therefore important to design glazing and devices which enable light and heat flow to be controlled.

#Is the glazing to wall ratio compliant with SANS 204 (SABS 2008)?
#Is solar shading compliant with SANS 204 (SABS 2008)?
#Has glazing with appropriate U-values, visual transmittance and solar heat gain coefficients been selected?

===Opening areas===
Opening areas within the building envelope such as doors and windows can be used to naturally ventilate the building. In general, it is advisable to provide for openings even in facilities that are mechanically ventilated and cooled as this enables them to be occupied and used in the event of a power cut.

#Are opening areas located to support effective natural ventilation?
#Is the area of openings provided compliant with SANS 10400 XA:2011?

Air tightness

Uncontrolled infiltration and airflow through the building envelope can affect comfort and increase heating and cooling loads in the building.

#Has careful detailing and specification been used to minimise infiltration in the building.
#Has a plan for rigorous construction supervision been put in place to ensure that building envelopes are air tight?

===Mechanical systems===
As far as possible mechanical cooling, heating and ventilation should be avoided. If this is not possible, a mixed mode operation should be selected. Mixed mode operation use mechanical system when ambient and internal conditions require this, but otherwise rely on passive systems to maintain thermal comfort and meet ventilation rate requirements. In particular circumstances mechanical cooling, heating and ventilation may be required for much of the year.

#Can the building or most of the spaces be passively cooled, heated and ventilated without the requirement for mechanical systems?
#If the application of passive systems will not achieve an acceptable number of annual comfort hours, can complementary mechanical systems be introduced to meet the comfort and ventilation requirements?
#Where zones exist within a facility that are not tolerant of passive ventilation and comfort systems, can a zoned mixed mode ventilation strategy be adopted?
#Where mechanical systems have been used has a rigorous exercise been undertaken to identify the most appropriate and energy efficient system?
#Where mechanical systems have been used do these include features that help reduce energy consumption such as:

a. An economy cycle

b. Controls that enable easy systems adjustments in order to benefit for seasonal and occupancy changes.

===Equipment===
As equipment used in building can consume large amounts of energy, the energy efficiency of equipment and energy ratings should be a key consideration. In addition, controls that ensure equipment is switched off when not in use should be specified.

#Is energy efficiency a key consideration in the selection of equipment?
#Is benchmarking energy consumption or energy rating used to support the selection of equipment?
#Are the controls provided for equipment easy to use and do they ensure that equipment is off when not required?

===Internal lighting===
Ensuring adequate lighting levels may be a key consideration in many spaces within health building. This should however be achieved in the most energy efficient way. Lighting is rapidly becoming more energy efficient and there are increasingly sophisticated controls.

#Is energy efficiency a key consideration in the selection of lighting?
#Has a rigorous evaluation process, including lighting power density calculations, been undertaken to ensure that the selected lighting system is highly energy efficient?
#Have appropriately sized lighting zones (ie under 100m2) been designed to avoid lighting being on where it is not required.
#Are lighting switching arrangements easy to use and encourage users to switch off lighting when not required?
#Are motion sensors used to switch lighting off in areas such as store rooms and meeting rooms when these are not used?
#Are daylight sensors used to switch lighting off in areas where these is adequate daylight? Areas with good daylight are usually found within a zone of about 6 m from external windows.
#Can light harvesting techniques and systems be incorporated in the design solution?

===External lighting===
Concerns about security often result in highly lit external areas. While security and building access requirements must be met, external lighting should be designed to be as energy efficient as possible.

#Are only areas that specifically require external lighting included?
#Has external lighting been provided as close to the area that requires lighting as possible and directed in order to avoid losses and light pollution?
#Are photo sensors, motion sensors or timers used to ensure that lighting is only on when required?

===BMS system===
Building Management Systems (BMS) should be used in complex building with complex equipment and systems. A BMS enables different systems to integrated and controlled and can support energy efficiency

#Has a BMS been used to coordinate and integrate systems, where complex systems are used in a large building?
#Is the BMS easy to use and understand?
#Is there local training and support for the BMS>
#Is the BMS system developed to open protocols and standards?
#Does the BMS include features that support energy efficiency such as:

a. Easy access to equipment schedules so that these can easily be changed to suite occupancy patterns.

b. Reminders to ensure that BMS operator tune building systems for greatest energy efficiency. For instance the system may provide a reminder to change air conditioning set points to match seasonal changes.

c. Reporting on water and energy sub metering and related equipment schedules.

===Sub metering===
An appropriate sub-metering system enables effective energy management. A facilities manager can see how much energy is used in different areas or uses in the facility. Sub-meters also show when and how energy is used through for instance energy profiles which show energy consumption and demand over time.

#Has an energy sub metering design been developed that will monitor all of the main energy uses in the facility?
#Is energy management data provided in formats and reports that can be easily understood and analyzed to support improved energy management?
#Does the system provide energy management report that can be used by both facilities managers and senior managers to improve energy efficiency in the facility?

===Renewable energy===
Increasingly renewable energy is becoming a competitive alterative to ESKOM supplied power. It also has the advantage that it increases the energy autonomy and independence of facilities, allowing these to operate even when there are mains power cuts.

#Are solar water heaters used to heat water in the facility?
#In areas with high quality, reliable sunlight, are photovoltaic systems used to reduce the reliance on ESKOM power?
#In areas with high quality, reliable wind, are wind turbines used to supplement to reduce the reliance on ESKOM power?

==WATER==

===Objective===
The building minimises the consumption of mains potable water.

===Introduction===
Water is used in health facilities for cleaning equipment, utensils and facilities, laundry, irrigation, food preparation and for drinking. In most existing South African health facility it is possible to reduce mains potable water consumption at no or low cost. These savings can be considerably higher in new facilities where water efficient technologies, grey water and rainwater systems can be used.

Ensuring that health facilities are more water efficient has a wide range of benefits including:

*Reduced water consumption and associated negative environmental impacts
*Reduced impact of mains water shortages or outages
*Reduced operational costs

===Water consumption in health facilities===
Water in South African health facilities is largely sourced from municipal potable water supply, however in some areas water may come from a rain water tanks or a borehole. The proportions of water use in a conventional South African hospital and clinic are shown in the pie charts below:
{| class="wikitable"
|+
!
!
|-
|Proportions of water consumption in a typical South African hospital
|Proportions of water consumption in a typical South African clinic
|}



Data on energy consumption and demand in South African facilities is not readily available. However the following table provides a number of benchmarks 1
{| class="wikitable"
|+
!Water benchmark type
!Typical
!Good practice
|-
|Clinics
|
|
|-
|Water consumption (kl/m2.a)
|1
|1
|-
|Hospitals
|
|
|-
|Water consumption (kl/m2.a)
|70 2
|1
|}
 

===Criteria===
The consumption of mains potable water in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective performance requirements within the health facility; however a series of questions can be used to check that key water considerations have been addressed. These are outlined below.

===Wash Hand Basin Taps===
Controlling and reducing water flows in wash hand basin taps can be used to reduce water consumption.

#Are wash-hand basin tap flow rates should not exceed 6L/minutes?
#Are passive infra-red (PIRs) or push-button controls used to limit the duration of flows?
#Has legionella control been considered when designing for low flow and systems and where existing system are made redundant?

===Toilets===
Reducing flush rates in water-borne sanitation can be used to reduce water consumption.

#Have WC flush rates been specified that do not exceed 6L/flush?
#Have dual flush controls can be used to ensure that reduced flush rates can be used when full flushes are not required?

===Showerheads===
Controlling and reducing water flows in showers can be used to reduce water consumption. The following measures can be considered:

#Have shower head flow rates been specified to not exceed 10L/minute?
#Are push-button type controls used to limit the duration of flows?
#Has legionella control been considered when designing for low flow and systems and where existing system are made redundant?

===Irrigation===
Minimizing irrigation water requirements can be used to reduce water consumption. The following measures can be considered:

#Are locally indigenous species (species found in the local area) used to minimise irrigation requirements?
#If irrigation is required, are highly efficient water delivery systems, such as a drip irrigation linked to soil moisture probes, used to minimise irrigation requirements.
#Has grey water been used to avoid the use of potable water for irrigation?

===Grey water systems===
Grey water systems reduce mains potable water consumption by reusing lower quality water within the facility. Examples of this are where waste water from showers and wash hand basins is captured and reused to flush toilets. Other sources of grey water include waste water from laundries and HVAC systems. Grey water systems however are potentially hazardous to human health, particularly in health facility environments. In particular, grey water which is left to stand for over 36 hours or is contaminated by food or similar waste is considered as blackwater and requires the same treatment as sewage. Therefore, grey water systems should only be designed, implemented and operated by appropriately competent people. Potential grey water applications in health facility environments are described below:

*Wash hand basin and shower waste water: Waste water from wash hand basins and showers can be directed to a grey water system and then used to flush toilets or for landscape irrigation.
*Vehicle wash: Waste water from vehicle waste can be reused to wash vehicles for up to 3 or 4 times. After this it can be disposed of or used for irrigation.
*HVAC plant: It may be possible to use waste water from HVAC systems for irrigation or to flush toilets. To ascertain if this is possible investigations should be carried out with the HVAC manufacturer and grey water specialists.

The following considerations in relation to grey water systems should be made:

*Have significant sources of grey water from, for instance, showers and wash-hand basins, been captured in a grey water system?
*Are grey water usage points appropriately labelled to prevent unsafe consumption.
*Will this grey water be used for irrigation or to flush toilets in order to significantly reduce portable water consumption?
*Is the proposed grey water system easy and cost effective to maintain?
*Have as many of the potential health hazards associated with the system been eliminated?

===Rain water systems===
Rain water systems store water captured from roofs or hard landscape surfaces. This water is then available for irrigation, to flush toilets or for cleaning. In large facilities very substantial amounts of water can be captured and used to reduce mains potable water consumption. A number of different types of systems are described below:

*Roof rainwater harvesting: Rainwater from roofs is directed to tanks and stores. Usually a proportion of initial run-off is directed to waste as it may have picked up dust and other debris. This system is the most common and generally has the lowest cost as rainwater tanks can be installed above ground surface.
*Hard surface rain water: This system captures storm water run-off from hard surfaces such as game pitches, paths and car parking. This type of system generally requires some form of filtration to remove debris, and in the case of car parking, oil wastes. Tanks are usually sub-surface.
*Landscape surface run-off capture: Surface run-off from soft landscaping can be captured and reused. This is sometimes used as part of an onsite storm water retention strategy. The disadvantage of this system is that the resulting water quality can be poor as debris and silt may be picked up. The filtration and maintenance requirements are therefore more stringent.

The following considerations in relation to rain water systems should be made:

#Have significant sources of rain water from roof and hard surfaces been captured in a rainwater harvesting system?
#Will this rain water be used in functions such as irrigation or to flush toilets in order to significantly reduce portable water consumption?
#Is the proposed rainwater harvesting system easy and cost effective to maintain? Have as many of the potential health hazards associated with the system been eliminated?

==WASTE==

===Objective===
The building minimizes waste directed to landfills.

===Introduction===
Waste in South African health facilities is largely directed to landfill sites. Not only does this use up valuable land, but can also lead to air, soil and water pollution if not waste is not disposed of correctly. In addition, this waste also consists of valuable resources that could be easily reused and recycled. Recycling and reusing materials not only reduces energy and resource consumption but can also create jobs and additional revenue streams.

Ensuring that health facilities minimise waste and reuse and recycle waste products are as follows:

#Reduced loss of land area to landfill
#Reduced energy and resource consumption
#Potential to create jobs and small enterprises

===Waste production in health facilities===
Waste in South African health facilities is largely directed to landfill sites. However in some area waste may be disposed of by local recyclers. The proportions of waste generated use in a conventional South African hospital and clinic are shown in the pie charts below:
{| class="wikitable"
|+
!
!
|-
|Proportions of waste in a typical South African hospital
|Proportions of waste in a typical South African clinic
|}

Data on waste in South African facilities is not readily available. However the following table provides a number of benchmarks 1
{| class="wikitable"
|+
!Waste benchmark type
!Typical
!Good practice
|-
|Clinics
|
|
|-
|Waste production (kg/m2.a)
|1
|1
|-
|Proportion of waste recycled or reused
|10%
|
|-
|Hospitals
|
|
|-
|Waste production (kg/m2.a)
|1
|1
|-
|Proportion of waste recycled or reused
|10%
|
|}

===Criteria===
Waste in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that key waste considerations have been addressed. These are outlined below.

===Provision for recycling===
Recycling can be encouraged by developing systems that make this easy. This includes providing easy-to-use receptacles for different types of waste and providing space in the right locations so that waste can be stockpiled into worthwhile quantities for a recycler to collect.

#Are there appropriate waste receptacles at the waste source to enable waste to be disposed of easily?
#Are there adequate number and type of waste receptacles at source to ensure that the value of waste is not reduced as a result of wastage or mixing of waste? For instance, clean waste paper can be spoilt if mixed with food waste.
#Has adequate storage space been provided in an appropriate location for the different recycling waste streams so that this waste can be stockpiled and easily accessed recycling contractors?

===Engagement with local recyclers===
Engaging with local recyclers earlier in the development of a new or refurbished facility can be used to understand the recycling process and the key requirements to make this effective.

#Have all the potential waste streams been identified? These include paper, cardboard, tin, glass, plastic, timber, electrical appliances etc?
#Have appropriate associations and local recyclers related to each of these waste streams been engaged with a view to ensuring that appropriate provision and systems are put in place to maximised recycling.

===Engagement with suppliers===
Engaging with suppliers can be used to reduce waste and transportation impacts. Waste and transportation impacts can be reduced through reduced use of packaging, use of reusable containers and optimized logistic supply chains.

#Have all suppliers of substantial goods and services to the health facilities been identified? Have these been engaged in relation to transportation and packaging with a view to minimising impacts in these areas?
#Has provision been made to reduce packaging waste and transport impacts through aspects such as increased space allowances for releasable containers and storage of products?

===Construction waste===
Construction is a major source of landfill waste. Waste from construction however can usually be easily reduced through explicit planning and monitoring processes.

#Has was construction waste minimization and recycling been included as specific requirement within tender and contract documents?
#Has the contractor been asked to develop a construction waste management plan in order to minimise waste? Does this plan include specific construction waste management targets ie 50% of all waste on site will be recycled? Have the parties responsible for implementing the plan been identified clearly and have they been given the mandate and resources to implement the plan? Has an appropriate monitoring and evaluation systems been put in place to ensure targets are achieved?

==MATERIALS==

===Objective===
Construction impacts of building are minimized

===Introduction===
Materials used in new facilities and the refurbishment of facilities can have significant impacts. Materials may be mined, processed, manufactured and transported before being incorporated in facilities. The extent and nature of the impacts of these stages varies widely depending on the material. The selection of materials and products to be used in facilities therefore is important in reducing negative environmental impacts.

Careful selection of construction materials used in health facilities has the following benefits:

*Reduced land and mining impacts
*Reduced environmental and health impacts from manufacturing processes
*Reduced transportation impacts
*Reduced material use
*Increased use of local sustainable materials

===Material use in health facilities===
Materials are used to construct South African health facilities and largely found in the building structure and envelope. More specialist materials and products such as refrigerants are found in equipment and systems within the building. The source and processes associated with construction materials and products have a wide range of impacts. It is therefore important to understand and confirm these with respective suppliers in order to select and specify materials and components with the least negative impacts.

===Criteria===
Material and component selection in health facilities can be addressed developing criteria list, communicating this to suppliers, and using this as a basis for specification and design. The nature of these criteria will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that key material and component considerations have been addressed. These are outlined below.

===Building reuse===
Using existing facilities instead of building new avoids or reduces the requirements for construction materials and therefore the impacts associated with extracting, manufacturing and transporting these. In addition, existing facilities are usually part of the urban fabric and already serviced with electricity, water, roads and public transport. Increasing the intensity of use of this fabric increases its efficiency and avoids the requirement to replicate this elsewhere. Therefore, in most circumstances it is preferable to reuse and refurbish existing facilities rather than build new facilities.

#Can the existing facilities continue to be used? If necessary, can these be refurbished and expanded rather than building a new facility?
#Are there other existing facilities that can be used? Can these be readily adapted for health use rather than constructing new facilities?

===Contribution to Global Warming===
Construction materials can contribute to global warming through carbon emissions associated with large amounts of energy used in their extraction, processing and transportation. This is referred to as embodied energy. Other materials such as refrigerant can contribute directly to global warming if they are released or leak into the atmosphere. Using existing facilities instead of building new avoids or reduces the requirements for construction materials and therefore the impacts associated with extracting, manufacturing and transporting these. In addition, existing facilities are usually part of the urban fabric and already serviced with electricity, water, roads and public transport. Increasing the intensity of use of this fabric increases its efficiency and avoids the requirement to replicate this elsewhere. Therefore, in most circumstances it is preferable to reuse and refurbish existing facilities rather than build new facilities.

#Refrigerants: Where refrigerants are being used in HVAC systems, cold rooms or in fire suppressions sytems have refrigerants with the lowest Global Warming Potential (GWP) and Ozone Depleting Potential (ODP) impacts been selected?
#High embodied energy materials: As far as possible, have construction materials with low embodied energy such as timber been selected? Where it is not possible to use these type of materials and high embodied energy materials such as cement and aluminium have to be use have the quantities of these materials been minimised?

===Reused materials or materials with recycled content===
Construction materials that are reused or have recycled content have less energy associated with their manufacture than equivalent new materials. Where possible, it is therefore preferable to reuse materials that may have already been used in another building or to select materials with recycled content.

#Are there materials from another building that is being demolished that could be reused? Aspects that can be reused include structure steel elements, facades, demountable structures such as carports, and building components such as windows and doors. Crushed concrete from demolished structures can also be used as aggregate in new construction.
#Have materials with recycled content been specified in preference to materials without any recycled content? Can the supplier / manufacture confirm the reduced environmental impacts of their recycled content product relative to new products?

===Reduced material use===
The quantity of construction materials used in facilities can be reduced through avoiding material use, using materials more intelligently and using materials for more than one use.

#Avoided material use: Have materials been avoided where these are not required? For instance, can ceilings and plastering be avoided through better concrete finishes? Can improved floor finishes be used to avoid the requirement for carpets and tiling? Can the use of passive systems reduce the requirement for ducting and plant?
#Intelligent material use: Can quantities of materials be reduced through different designs and specifications? For instance, can structural strategies such as pre-tensioning concrete slabs and waffle slabs be used to reduce concrete requirements? Can material use and wastage be reduced through use of precast elements?
#Dual plus use: Can materials be used for more than one purpose? For instance, can photovoltaic panels be used as a roofing material as well as to generate material?

===Material source===
The quantity of construction materials used in facilities can be reduced through avoiding material use, using materials more intelligently and using materials for more than one use.

#Avoided material use: Have materials been avoided where these are not required? For instance, can ceilings and plastering be avoided through better concrete finishes? Can improved floor finishes be used to avoid the requirement for carpets and tiling? Can the use of passive systems reduce the requirement for ducting and plant?
#Intelligent material use: Can quantities of materials be reduced through different designs and specifications? For instance, can structural strategies such as pre-tensioning concrete slabs and waffle slabs be used to reduce concrete requirements? Can material use and wastage be reduced through use of precast elements?
#Dual plus use: Can materials be used for more than one purpose? For instance, can photovoltaic panels be used as a roofing material as well as to generate material?

===Sustainable sources===
Materials can be defined in terms of whether they are from sustainable or non-sustainable sources. Materials from sustainable sources include timber, cork, wool that are grown and therefore can be harvested on an on-going materials. Other materials such as plastics and metals are mined and therefore once these sources are depleted will not be available.

#Where possible, have materials from sustainable sources been specified? For example, have timber, and plant-based products been used in preference to materials that have to be mined and processed?
#Are materials from sustainable sources actually being grown and harvested on a sustainable on-going basis? For instance, has timber specified been certified by the Forest Stewardship Council (FSC) as being from a sustainable source? It is important to note that there are still timber products available, in particular hardwoods, that are harvested from tropical rainforests which are not being replanted and therefore are not considered sustainable sources.

===BIODIVERSITY===

===Objective===
The building supports biodiversity

===Introduction===
Biodiversity plays a very important role for man through providing ecosystem services. Ecosystem services include the production of food and water, the control of climate and disease, supporting nutrient cycles and crop pollination and spiritual and recreational benefits.

Ensuring that health facilities take into account biodiversity has a wide range of benefits including:

*Maintaining local ecosystem services
*Providing an natural amenity such as gardens which would could support recuperation.

===Biodiversity in health facilities===
Health facilities affect biodiversity through their location and in the way that site planning and landscaping is carried out. New facilities can minimise negative impacts on biodiversity by avoiding green field sites and building outside municipal boundaries. Biodiversity within health facility sites can be supported through considered site planning and landscaping strategies.

===Criteria===
Biodiversity in health facilities can be addressed in a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key biodiversity considerations have been addressed. These are outlined below.

===Site location===
Biodiversity is being lost at a rapid rate through urban sprawl. Preserving existing biodiversity can therefore be achieved by avoiding green field site and building only within urban boundaries.

#Has the health facility been planned for a brown field (already built-on) sites?
#Has the health facility been planned for a location within an urban boundary so that this does not take up land that supports agriculture and or biodiversity.

===Design for biodiversity===
Biodiversity can be supported through site layouts and landscaping that retains existing biodiversity and enhances this.

#Has planning of the health facility ensured that existing valuable biodiversity on site is preserved?
#Have valuable links and wildlife corridors between biodiversity on the health facility and adjacent sites been preserved?
#Has the landscaping strategy enhanced existing biodiversity? Does this include the introduction of appropriate loc

==TRANSPORT==

===Objective===
The building supports energy efficient transportation

===Introduction===
Ensuring that health facilities support energy efficient transportation has a wide range of benefits including:

*Reduced air pollution and noise from vehicles
*Health benefits from increased opportunities for exercise
*More affordable transport for health facility users
*Reduced space requirements as a result of reduced parking and road requirements.

===Transportation in health facilities===
Transportation is important in health facilities as large numbers of people and goods need access to these facilities everyday. This includes health facilities staff who commute and health facilities users. The right location and provision of facilities help ensure that the transport impacts associated with this access is minimized and potential health benefits such as exercise are supported.

===Criteria===
The transportation in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that transportation considerations have been addressed. These are outlined below.

===Access to public transport===
Locating health facilities near public transport facilities and enabling good access to these encourage people to use these in preference to personal vehicles. The use of public transport can be encouraged by ensuring that health facilities are located near well used public transport nodes and that there are good walking routes between these and key locations within the health facility.

#Is the health facilities located near good public transport nodes such as minibuses, buses, trains and bus rapid transport systems?
#Are there safe, direct and easy-to-use routes between public transport nodes and key locations within the health facility? (see also provision for walking criteria)

===Provision for walking===
Making provision that encourages walking helps to ensure that people walk to health facilities instead of using vehicles. Walking can be encouraged through safe, direct and easy-to-use routes.

#Are there safe direct pedestrian routes to and around the health facilities site from neighboring areas and public transport nodes? (see also criteria 4 for detail)
#Are there safe direct pedestrian routes from neighboring areas to key locations within the health facility such as the main reception? (see also criteria 4 for detail)
#Are there safe direct pedestrian routes within the health facilities between all locations within the health facility? (see also criteria 4 for detail)
#Does pedestrian provision include safe road crossings such as bridges, underpasses and zebra crossings? Are routes wide enough and have appropriate finishes and other required characteristics to enable them to be easily used by people with disabilities and by predicted pedestrian numbers? Are routes safe and benefit from visual supervision by surrounding facilities and other pedestrians? Have lighting and appropriate security safety mechanisms been put in place if routes will be used at night?

===Provision for cycling===
Making provision that encourages cycling helps to ensure that people cycle to health facilities instead of using motorized vehicles. Cycling can be encouraged by providing secure cycle storage, changing or showering facilities and safe, easy-to-use local routes.

#Are there safe direct cycle routes to and around the health facilities site from neighboring areas? (see also criteria 4 for detail)
#Are there safe direct cycle routes from neighboring areas to key locations within the health facility such as the main reception? (see also criteria 4 below for detail)
#Are there safe direct cycle routes within the health facilities between all locations within the health facility? (see also criteria 4 for detail)
#Does this cycle provision include designated, separate routes and safe road crossings and junctions? Are routes wide enough and have appropriate finishes and other required characteristics to enable them to be easily used by predicted numbers of cyclists? Are routes safe and benefit from visual supervision by surrounding facilities and other cyclists? Have lighting and appropriate security safety mechanisms been put in place if routes will be used at night?

==RESOURCE USE==

===Objective===
The building makes efficient use of resources

===Introduction===
There are limited resources in the form of land, finance and raw materials to construct and maintain facilities. It is therefore important to use these resourced carefully. Benefits associated with careful resource use include:

*Avoiding waste
*Ensuring effective and efficient use of resources
*Ensuring that resources are available for other uses where these are not required

===Resource use in health facilities===
Health facilities use financial resources to enable construction and maintenance. They also consume materials and energy in their construction. Finally health facilities use land. Careful use of these resources enables waste to be avoided and these resources to be available for other uses where this is required.

===Criteria===
Resource in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that key resource considerations have been addressed. These are outlined below.

===Site density===
Detailed long term strategic plans for health facilities should be developed that take into account future projections. These should ensure that expansion or changes that are envisaged can be accommodated. However care should be taken that unnecessarily large areas are allocated for health facilities to avoid land being unused.

#Has a long term strategic site plan been developed for the health facility that addresses changes that may occur in the future, such as expansion or contraction?
#Has the over allocation of space for health facility sites been avoided?

===Occupancy density===
Robust sustainable facilities accommodate change through flexible and adaptable allocation and configuration of space. While this is important over provision of space should be avoided as this space will need to be serviced and maintained even if it is not used. Health facilities should therefore be designed to support spatial efficiency and effective use.

#Is the overall space allowance in the health facility in line or below health facilities norms, for instance, in terms of gross area per bed?
#Are the proportions of spaces use in the health facility in line with good practice health facilities design? For instance is the space allocated for circulation, support and ancillary services as a proportion of the total area in line with best practice norms?

===Food production===
Food production in the form of orchards or vegetable gardens are a productive way of using land that leads to both environmental and health benefits. Where land is available in health facility sites and there is water and appropriate capacity, food production should be encouraged and produce made available to be consumed within the health facility or by local communities.

#Has available land within the health facility site been developed for local food production?
#Has appropriate provision in the form of irrigation, fencing, organizational and capacity requirements been made to ensure that food production will be effective and sustained?

==MANAGEMENT==

===Objective===
The building is managed to support sustainability

===Introduction===
Facilities can be designed to support effective management. Systems can also be developed to ensure that facilities are effectively and efficiently used and maintained. In health facilities this is particularly important because of the stringent environmental requirements for health care and the high operating costs of the facility.

Ensuring that health facilities are effectively managed has a wide range of benefits including:

*Ensuring that operating costs are controlled and reduced
*Minimising disruption to health care as result of maintained and repairs
*Ensuring that maintenance is planned for and effective carried out

===Building management in health facilities===
Building management aims to ensure that health facilities are effectively operated and maintained in order to support healthcare services that they accommodate. Personnel with appropriate capacity, mandate and resources should be allocated to this function.

===Criteria===
Building management in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that building management considerations have been addressed. These are outlined below.

===Energy and water sub metering===
Energy and water sub metering enables the manager of a health facility to manage the consumption of energy and water and reduce costs associated with these services.

#Has energy sub metering been installed which enables energy consumption in all areas with substantial loads to be measured and monitored? Do energy meters support assessment of energy consumption trends, profiles and comparison with benchmarks?
#Has water sub metering been installed which enables water consumption in all areas with substantial consumption to be measured and monitored? Do water meters support assessment of water consumption trends, profiles and comparison with benchmarks?
#Is water and energy consumption monitored and reported to senior management on a regular basis?

===Facilities management manual===
A facilities management manual provides technical detail on all aspects of the building and how they should be maintained and managed. It is useful because it provides a repository of knowledge and information that can be used by facilities managers and their staff to ensure that health facilities are effectively managed and maintained.

#Has a detailed facilities management manual been developed for the health facilities? Does this include a detailed schedule for maintenance and other checks on equipment such as lighting, pluming fittings and HVAC
#Does the facilities management manual refer to a full set of as-built drawings and equipment manuals? Have a full set of hard copy and electronic copy as-built drawings and manuals been provided?
#Have facilities managers in the building had a full induction on the building’s systems and the facilities management manual?
#Does the facilities management manual get regularly reviewed and updated to reflect upgrade and renovations details.

===Senior management commitment===
Effective management of facilities can be supported by senior management commitment. Regular reporting on facilities performance such as energy and water consumption serve to ensure that management is aware of these issues and are likely to ensure that the appropriate mandate and resources are in place to improve this.

#Have facilities management policies in relation to sustainability been developed? For instance, are there policies or guidance on how energy and water consumption will monitored and managed?
#Have facilities management policies or guidelines been endorsed by senior management? Is there are requirement for facilities management to report on facilities performance on a regular basis to senior management?

==LOCAL ECONOMY==

===Objective===
The building supports the local economy

===Introduction===
The construction and maintenance health facilities are a significant investment by government. This investment, if considered carefully, can be used to support the local economy and employment. This is done by specifying local products and services from the local area.

Ensuring that health facilities support the local economy has a wide range of benefits including:

*Increased local employment
*Increased local capacity for new construction and maintenance of facilities

===Local economy in health facilities===
Supporting the local economy can be achieved in new facilities by understanding the nature and type of local building product suppliers and where appropriate specifying these in the building. Similarly understanding the capacity and skills of local contractors can be used to ensure that these are developed and enhanced by being engaged in the construction and maintenance of health facilities.

===Criteria===
Supporting the local economy in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key waste considerations have been addressed. These are outlined below.

===Small enterprise support===
The waste and emissions in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key waste considerations have been addressed. These are outlined below.

Minimizing irrigation water requirements can be used to reduce water consumption. The following measures can be considered:

#Are small enterprises provided with opportunities to tender for relevant construction and maintenance contracts? Can local, small enterprises be given preference in the awarding of work?
#Where local small enterprises have limited capacity and experience, can they be supported by encouraging partnerships with more established and larger enterprises?

===Material and component procurement===
The specification of local materials and components in the construction of health facilities can provide a significant incentive to local suppliers and manufacturer to develop appropriate products and capacity. This in turn provides local employment and can ensure that maintenance and repairs at the facilities can be carried out more quickly and cost effectively.

#Has a review of local materials and components been carried out?
#Have local materials and components been specified?

===Construction employment===
The construction industry can employ significant numbers of people. This can be supported through designs, specifications and labour intensive construction techniques which can be used to construct facilities without significant cost or time implications. Local construction employment improves the local economic impact of projects and ensures that there is local capacity to undertake repairs and maintenance of facilities.

#Is construction employment a key consideration in the design, specification and construction of the facility?
#Have opportunities to create local employment been sought and developed through the project?

==PRODUCTS AND SERVICES==

===Objective===
The building supports use of more sustainable products and services

===Introduction===
Products and services used in health facilities have a range of impacts and planning can be used to maximise beneficial impacts and avoid negative impacts. The construction and maintenance health facilities are a significant investment by government. This investment, if considered carefully, can be used to support the local economy and employment. This is done by specifying local products and services from the local area.

Ensuring that health facilities support the more sustainable products and services has a wide range of benefits including:

*Reduced waste
*Increased support for sustainable choices and options for health facility users

===Products and services in health facilities===
Supporting the local economy can be achieved in new facilities by understanding the nature and type of local building product suppliers and where appropriate specifying these in the building. Similarly understanding the capacity and skills of local contractors can be used to ensure that these are developed and enhanced by being engaged in the construction and maintenance of health facilities.

===Criteria===
Supporting the more sustainable products and services in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key product and service considerations have been addressed. These are outlined below.

===Local produce===
Impacts associated with transport and storage / refrigeration mean that produce imported from some distance away generally has significantly higher ecological footprints than local produce. Health facilities can therefore reduce ecological footprints associated with food through using local produce as far as possible.

#Is local produce used in preference to produce imported some distance away?
#Has the use of local produce been made a requirement in outsourced catering contracts?

===Vegetarian options===
Meat-based meals generally have significantly higher ecological food print requirements relative to vegetarian meals. Providing vegetarian options can therefore support reduced food impacts within health facilities.

#Are vegetarian options provided in catering establishments within the health facility?
#Has the provision of vegetarian options been made a requirement for outsourced catering contracts?

===Drinking water===
Waste streams can be reduced by providing alternatives to bottled drinking water. Drinking water can be provided through strategically located drinking fountains, as well as being supplied in reusable containers. A ready supply of drinking water also has health benefits.

#Is non-bottled drinking water readily and freely available throughout the health facility?

===Reuseable vessels===
Significant waste streams can be avoided through the use of reusable vessels. In particular disposable food and drink vessels can be avoided by providing reusable vessels. This option can be supported through provision of required storage and washing and facilities.

#Have reusable vessels been specified in preference to disposable containers, for services such as catering?
#Has adequate provision been made for reusable vessels in the form of storage and washing facilities?

==ACCESS==

===Objective===
The building supports access to facilities

===Introduction===
Current work patterns and lifestyles mean that many people have to access facilities such as banking, retail, childcare and communications on a regular basis. Ensuring that these facilities are within the health facility or within easy walking distance helps to avoid or reduce associated time and transport impacts.

Ensuring that health facilities support access to facilities has a wide range of benefits including:

*Reduced transport impacts
*Reduced time spent travelling to and from facilities

===Access to facilities in health facilities===
Supporting access to local facilities can be achieved through incorporating these into the health facility. Alternatively the health facility can be located near where these exist. It may also be possible to work with relevant service providers in order to provide these locally.

===Criteria===
Supporting access to facilities in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key access considerations have been addressed. These are outlined below.

===Banking===
Access to banking can be provided through formal banking facilities or through bank ATMs. This can be provided within the health facility or within easy walking distance of this.

#Are banking facilities available within the health facilities or within the local area?

===Grocery retail===
Grocery retail can be provided through local shops, supermarkets and markets. This can be provided within the health facility or within easy walking distance of this.

#Are grocery retail facilities available within the health facility or within the local area?

===Communication===
Access to telephone and internet can be provided through internet cafes or at stand alone kiosks. This can be provided within the health facility or within easy walking distance of this.

#Are internet and telephone facilities available within the health facility or in the local area?

===Café===
Access to catering facilities can be provided through cafes, restaurants or canteens. Refreshments should be affordable and accessible to both staff and health facility users. This can be provided within the health facility or within easy walking distance of this.
1. Is there an accessible, affordable café, restaurant or canteen within the health facility or in the local area?

===Childcare===
Significant waste streams can be avoided through the use of reusable vessels. In particular disposable food and drink vessels can be avoided by providing reusable vessels. This option can be supported through provision of required storage and washing and facilities.

#Is there a childcare facility within the health facility or in the local area?

==HEALTH==

===Objective===
The building supports a healthy and productive environment

===Introduction===
Health facilities by their definition aim to support health and well being in their users. In addition to medical care health can be promoted through beneficial environmental conditions including a plentiful supply of fresh air, views and optimum thermal comfort conditions. It is particularly important to avoid conditions and situations that may be harmful to human health.
Ensuring that health facilities support the health in facility users and construction workers services has a wide range of benefits including:

*Improved recovery rates for patients
*Reduced absenteeism associated with environmental conditions by health facility staff
*Reduce injury and absenteeism rates associated with dangerous or harmful working construction environments

===Criteria===
Ensuring construction and health facilities promote health can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that health promotion considerations have been addressed. These are outlined below.

===External views===
Views and a connection to the external environment improve internal environmental conditions and can help improve recovery rates and reduce employee absenteeism.

#Do health facility staff working areas have views to the external environment
#Do patient areas have views of the external environment?

===Daylight===
Day lighting can help reduce energy consumption associated with artificial lighting. It also improves internal environmental conditions for patients and health facility employees.

#Are health facility staff working areas well day lit?
#Are patient areas well day lit?

===Ventilation===
High levels of fresh air are important for human health and productivity. This can be provided through natural or mechanical ventilation. Where mechanical ventilation is used sufficiently high levels of external, fresh air should be provided and recirculated air should be avoided or minimized.

#If the condition of outside air makes it unfit for direct ventilation use, is it appropriately pre-treated and filtered by the ventilation system?
#Are health facility staff working areas well supplied with good quality outside air?
#Are patient areas well supplied with good quality outside air?

===Building materials===
Building materials can have negative impacts for human health associated with their extraction and manufacture. They may affect health in facilities, through for instance offgassing hazardous chemicals. Construction materials should therefore be screened to avoid products being used in health facilities that have negative impacts on human health.

#Has criteria been developed and applied for the selection and screening of building materials?
#Have all building materials that may off gas substances such as formaldehyde and volatiles organic components that may be harmful to human health been avoided?

===Contractor health and safety===
There are considerable health and safety risks in the construction industry. Considering health and safety in the design of health facilities can be used to reduce health and safety risks associated with construction and maintenance. Making provision for safe access to glass facades or to high level lighting helps to ensure that this can be installed, cleaned and maintained without undue health and safety risks. In addition, addressing health and safety comprehensively in contract and construction planning, procedures and processes can be used to eliminate many construction health and safety risks.

#Has contractor health and safety been considered as a key issue in the design of the building? Have construction risks been minimised through appropriate design risk assessments and mitigation?
#Have detailed construction plans, procedures and processes been developed to minimise risks where these may occur during construction?
#Has appropriate health and safety procedures been put in place to ensure that plans are implemented and monitored?

==EDUCATION==

===Objective===
The building supports education

===Introduction===
Education and on-going learning is increasingly been seen as an essential component of sustainable development and a competitive economy. This is recognised in health care through the requirement for health care professionals to under continued professional development (CPD). Education and on-going learning can be supported through technology and spaces within facilities that support this. Examples of this include training rooms and access to ICT and reading material. In addition well packaged
Ensuring that health facilities support the education has a wide range of benefits including:

*Improve ability by health facilities staff to keep up-to-date with new developments in health care
*Ability to attract and retain staff

===Criteria===
Ensuring construction and health facilities promote education and on-going learning can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that education and on-going learning considerations have been addressed. These are outlined below.

===Contractor education===
There are considerable health and safety risks in the construction industry. Considering health and safety in the design of health facilities can be used to reduce health and safety risks associated with construction and maintenance. Making provision for safe access to glass facades or to high level lighting helps to ensure that this can be installed, cleaned and maintained without undue health and safety risks. In addition, addressing health and safety comprehensively in contract and construction planning, procedures and processes can be used to eliminate many construction health and safety risks.

#Has contractor health and safety been considered as a key issue in the design of the building? Have construction risks been minimised through appropriate design risk assessments and mitigation?
#Have detailed construction plans, procedures and processes been developed to minimise risks where these may occur during construction?
#Has appropriate health and safety procedures been put in place to ensure that plans are implemented and monitored?

===Notice boards===
Notices are very easy and cost effective way of communicating information. They can be used to support education and awareness by drawing attention to new or important education. For instance, awareness and reminders about new health care policy, procedures and processes can be communicated. Notice boards have the benefit that they can be located where they will be seen by all personnel on a regular basis and are not reliant on a particular technology, such as email. This helps to ensure information can be communicated to all levels of staff within a health facility.

#Have notice boards been located in key locations in the health facility where they can be used to communicate key information to facility staff and users?
#Have communication and education plans been developed that will ensure that notice boards will be updated throughout the year with relevant notices and information?

===Space for learning===
Formal training can be supported through access to training rooms. More informal on-going learning can be provided through access to resource centres where learning material, computers and the internet can be accessed.

#Are there appropriately sized and equipped facilities to accommodate formal training?
#Are there appropriately sized and equipped facilities to support informal on-going learning by staff?

===Employee induction===
Employee induction refers to awareness training provided to new employees. This can be used to support sustainability by developing awareness in health facility staff about sustainable building systems and how they should be used. This may include aspects such as lighting and HVAC operation as well as recycling procedures.

*Have employee induction processes been developed?
*Do these include detailed information on systems in the building that aim to support sustainability?

===Building user manual===
Building user manuals aim to complement employee induction processes by providing easily accessible and understanding information related to a facility in order to support user behaviour that support sustainability.

#Has a building user manual been developed?
#Is this readily accessible and easy to use?

==INCLUSION==

===Objective===
The building is inclusive of diversity in population

===Introduction===
Design for inclusion helps to ensure that facilities can be used by all users including older people, sick people, people with children and people with disabilities. Inclusive design also often means that facilities are safer and easier to use. In health facilities both of these aspects are particularly important.

Ensuring that health facilities are inclusive has a wide range of benefits including:

*Less requirement to replicate facilities
*Facilities that are easier and safer to use

===Criteria===
Ensuring health facilities are inclusive can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key inclusion considerations have been addressed. These are outlined below.

===Accessible transport===
Inclusive access to health facilities is an important consideration. This means ensuring that people who may be ill, infirm, old or have disabilities are able to access health facilities easily. This requires accessible routes from places for work and accommodation to the facilities and often requires easily accessible local public transport systems. This can be p

Ensuring that health facilities support the education has a wide range of benefits including:

#Are there regular, affordable and efficient local transport systems?
#Can these be accessed readily from health facility users’ accommodation and places of work?
#Can the health facility be accessed readily from public transport?
#Is public transport provision inclusive?

===Environmental access===
Facility design and management for environmental access can be used to ensure that health facilities are inclusive. This requires a comprehensive approach that ensures that access consideration are effectively integrated into all aspects of health facility design. Guidance on this aspect is provided in the IUSS d

#Does the facility design fully comply with the IUSS environmental access requirements?
#Are systems and management in place to ensure that environmental access standards are maintained during operation?

===Access to affordable accommodation===
There is an increasing shortage of affordable accommodation in many South African cities. This can have a range of negative impacts including the requirement for long distance commuting, disrupted family life, and reduced family budgets for non-transport related costs such as education and health. Increasing local affordable accommodation can be achieved through partnership agreements with local developers and social housing organizations.

#Is there affordable local accommodation for health facility staff?
#If this does not exist, have initiative been taken to develop this with developers and or social housing institutions?

==SOCIAL COHESION==

===Objective===
The building supports social cohesion

===Introduction===
Social cohesion refers to the extent to which individuals within a community understand, collaborate, trust and work together. It is valuable because it enables collective knowledge and resources to be used more effectively and efficiently to support common goals. Within a health facility improved social cohesion can support improved healthcare with fewer resources by sharing and using these more effectively. It can also support improved communication and cooperation within health teams and therefore improving levels of service and reducing wastage and mistakes.

Ensuring that health facilities support social cohesion has a wide range of benefits including:

*More efficient and effective use of resources
*Improved communication and coordination
*Reduced wastage

===Criteria===
Ensuring health facilities support social cohesion can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key social cohesion considerations have been addressed. These are outlined below.

===Shared used of facilities===
Shared use of facilities helps to ensure that valuable facilities are well used and beneficial impacts are experienced across a wider range of people. Capital and operating costs of the facility may also be reduced as these are shared between a larger number of organizations or individuals. This concept can be applied to health facilities in a range of different ways. For instance, sharing arrangements with a local sport club or fitness center can be used to enable a health facility to use swimming pools and other facilities for rehabilitation without having the ongoing costs and management of this facility.

#Have shared use, and possibly development, of facilities been explored with local organizations?
#Have appropriate design considerations been put in place to ensure effective shared use of facilities?
#Have appropriate management considerations been put in place to ensure effective shared use of facilities?

===Social spaces===
Social spaces, such as canteens, cafes and common rooms can play an important role in the life of organization. They not only provide a respite from work environments they also provide a space for relaxed social interaction. This interaction and the relationships and communication networks created can may a significant impact in improving organizational effectiveness and responsiveness. In health care facilities this is a valuable resource which helps to motivate individuals and build strong teams that are able to provide effective and responsive health care.

#Have an appropriate number and type of social spaces been provided within the health facility?
#Will these facilities support easy social interaction within and between health teams, as well as cross health facility staff structures?

===Stakeholder involvement===
Involving people in decisions on issues will have an impact on them is a useful way of helping ensure that there is support for an initiative or a process. Structured involvement of stakeholder helps to ensure a shared understanding can be developed, joint decisions made and there is efficient and effective implementation. For instance, within a health facility, effective involvement of key stakeholders can help goals such as improved energy efficiency through ensuring that managers, building technical staff and health services staff understand the goal, the means that this will be achieved and can see their role in supporting this.

#Has there been appropriate stakeholder involvement in the design of health facilities?
#Has there been appropriate stakeholder involvement in the management of health facilities?

==REFERENCES==

#CIDB, 2009. South African Report on Greenhouse Gas Emission Reduction, Potentials from Facilities, A Discussion Document. Construction Industry Development Board. Page 22.
#. DEAT, 1995. Urban Open Space: Guidelines for effective management. Discussion document based on Agenda 21 and the RDP
#DEAT, 1998. National Environmental Management Act. Department of Environment and Tourism, Pretoria. Chapter 1.
#DEAT 2009, State of the Environment Report Accessible from http://soer.deat.gov.za/themes.aspx?m=387
#DEAT, 2009a, The National Climate Change Response Policy. Department of Environment and Tourism, Pretoria. Page 8.
#DEAT, 2009b, The National Climate Change Response Policy. Department of Environment and Tourism, Pretoria. Page 14
#DEAT, 2009c, The National Climate Change Response Policy. Policy Department of Environment and Tourism, Pretoria. Page 20.
#EMM and GDACE, 2007. Environmental Management Framework for Ekurhuleni. Ekurhuleni Metropolitan Municipality and Gauteng Department of Agriculture, Conservation and the Environment
#Hewitson, B. Engelbrecht, F Tadross, M. and Jack, C., 2005. General conclusions on development of plausible climate change scenarios for southern Africa, in: R. E. Schulze (ed.), Climate Change and Water Resources in Southern Africa: Studies on Scenarios, Impacts, Vulnerabilities and Adaptation, Water Research Commission, WRC Report 1430/1/05, Pretoria, South Africa.
#IPCC, 2007. Climate Change 2007, Synthesis Report. Inter Governmental Panel on Climate Change. 2007.Page 7
#SEA 2006, State of Energy in South African Cities. Sustainable Energy Africa. Cape Town.
#South African Bureau of Standards. 2007. SANS 204 Energy Efficiency in Facilities
#WWF 2006. Living Planet Report 2006.World Wildlife Fund. Accessed from www.panda.org.

==APPENDIX A: SUSTAINABILITY INTEGRATION PLANS==
 
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[[Category:Crosscutting Issues]]

Legionella Control

2020-10-29T04:08:05Z

Tmojanaga: /* References */

{{Stub}}
{{Anchor|Section1}}
==Section 1==
{{Expand}}

==Section 2==

==='''THE CHAIN OF INFECTION'''===
The mere presence of legionellae in a water distribution system does not necessarily imply a human health risk. For human infection to occur, certain conditions are necessary. These conditions are referred to as the “chain of infection” consisting of six links. All the links have to be present for disease to occur ([[#Legionella-Chain_of_Infection|Diagram: Chain of infection]] ). The first link, the pathogen, was discussed in [[#Section1|Section 1]].

{{Anchor|Legionella-Chain_of_Infection}}
[[File:Chain of infection.png|alt=Chain of infection|none|thumb|Chain of infection|450x450px]]

==='''SOURCES AND RESERVOIRS'''===
Legionellae are natural inhabitants of water, found a wide range of habitats. They are ubiquitous in streams, lakes and rivers. They also survive in dust, soil and mud. In fact, one of the species, ''Legionella longbeacheae'', is so often isolated from potting soil in Australia that soil has been suggested as the natural habitat of this particular species.

{{Anchor|Natural sources of Legionella}}
[[File:Natural sources of Legionella.png|alt=Natural sources of Legionella|none|thumb|Chain of infection|450x450px]]

Legionellae from these natural environments can be transmitted to man-made water systems by various means. For example, from raw water, during water treatment, as part of post-treatment after-growths within water distribution systems, during building and construction activities and during plumbing repair.

Once established, they can persist in the water supply for long periods of time and are difficult to eradicate. Therefore, their presence must be considered in all aspects of the design, operation and maintenance of buildings. For this to be effective, cooperation between engineers, occupational health practitioners and microbiologists is essential.

Figure 2.3 Man-made sources of Legionella

=====Water sources that provide optimal conditions for Legionella growth can be separated into those containing “non-potable” and those that contain “potable” water. '''Non-potable water distribution systems'''=====

Heat rejection devices like cooling towers, evaporative condensers and HVAC (heating, ventilation and air-conditioning) systems are often implicated as sources of legionellosis. They contain reservoirs filled with warm, recirculating water that makes them ideal for the growth, amplification and dissemination of micro organisms (including Legionella). In a typical water-cooled system air in induced through or blown over, packing material down which water, circulating from a pond under the packing, is allowed to fall by gravity, producing a large wetted surface that cools the falling water.

The constant fall of water through the tower, the large area of the basin, fill, pipes and heat exchanger, the warm temperature of the water, the high relative humidity and high organic content within these devices provide conditions that favour contamination by algae, protozoa, fungi and bacteria. The risk is increased further by the open nature of the systems, excessive aeration and the constant addition of fresh water to make up for water lost through evaporation.

In systems that are not regularly cleaned, sludge accumulates in the reservoir and slime adheres to water covered surfaces, resulting in the presence of large concentrations of micro-organisms, including legionellae, on these surfaces. In addition, water temperatures below 60°C, the age and configuration of the system, the pH of the water and the presence of certain metals may also increase the risk of contamination.

Water derived from municipal supplies but subsequently stored in cisterns, or conditioned prior to heating, is considered non-potable due to the deterioration in chemical and bacteriological quality during storage. Colonisation of such non-potable sources inside large buildings, such as hotels, factories or hospitals, may be a major cause of legionellosis.

====='''Potable (domestic) water distribution systems'''=====
Legionellae are often present in potable water supplies, especially in the hot water sections of these systems. The organisms may enter potable water supplies from the main source, even from municipal water, and survive standard treatment protocols because most municipal water systems are not routinely screened for the presence of legionellae and the organisms are chlorine tolerant. Once inside the system, they find a suitable environment to multiply and are usually very difficult to eradicate.

Legionella levels can rise from very low to very high within short periods of time. The factors that give rise to these fluctuations are not well understood and often very hard to determine. These factors include the age and configuration of the pipes, the degree of scaling and sediment and the potential for biofilm formation within the system increase the risk of contamination. Water temperatures of 25 – 42°C, stagnation and the presence of certain free-living amoebae capable of supporting the intracellular growth of legionellae are often mentioned as amplifying factors in published reports. The biofilm and scale that form on surfaces in water distribution systems provide nutrients for legionellae and protect them from hot water and disinfectants. Some materials used in these systems, for example neoprene washers, are more readily colonised than others (See [[Legionella Control#Materials used in the construction of potable water lines and fixtures|Table]]). Building location may also play a role in the colonisation of potable water with legionellae.

Hot water tanks are often colonised with legionellae, especially at the bottom where a warm zone may develop and scale and sediment accumulate. Hot water piping, especially dead-legs, presents an additional risk as legionellae thrive in stagnant water.

====='''Soil'''=====
Outdoors, the soil may be contaminated through contact with Legionella-polluted water and become a source of airborne bacteria during earth moving operations, such as construction work.
{| class="wikitable"
|+{{Anchor|Materials used in the construction of potable water lines and fixtures}}'''Materials used in the construction of potable water lines and fixtures'''
|
'''Very good'''
|
Copper
|-
|
'''Good'''
|

Neoprene

Other synthetic materials
|-
|
'''Reasonable'''
|
Steel
|-
|
'''Not recommended'''
|
Rubber

Plastics
|}

===='''Amplification'''====
Legionellae are usually present in low numbers in natural sources. However, certain factors present in man-made reservoirs can promote Legionella growth and amplification. To improve our understanding of Legionella, its potential to cause disease and how to better control the organisms in water systems, we must understand these conditions. The most important factors amplifying Legionella numbers in man-made reservoirs are listed in the table [[Legionella Control#Amplifying factors for Legionella in man-made sources and reservoirs.|Amplifying factors for Legionella in man-made sources and reservoirs.]]
'''Remember'''
Temperature data is usually based on laboratory studies and is not from actual system (piping) studies, which makes it even less reliable to use for Legionella control. System temperature on its own should therefore not be relied upon for Legionella control, because the so-called “system temperature” rarely indicates one uniform temperature throughout the entire system. Therefore, maintaining the system temperature does not guarantee Legionella control. Also, in plumbing systems, especially larger and/or more complex piping systems, legionellae have been shown to survive at even higher temperatures due to biofilm, dead-legs, and other complexities. It has been suggested that potable water systems be operated at temperatures as high as possible but take into account the risk of scalding injuries and energy conservation requirements.
{| class="wikitable"
|+{{Anchor|Amplifying factors for Legionella in man-made sources and reservoirs}}'''Amplifying factors for Legionella in man-made sources and reservoirs'''
|
'''TEMPERATURE'''
|

Legionellae can survive over a wide range of temperatures (20 – 60°C) with an optimum growth temperature of 37 – 45°C as illustrated in the figure [[Legionella Control#Natural sources of Legionella|Natural sources of Legionella]] 
|-
|
'''pH'''
|

Legionellae can survive and multiply at a pH of 5.0 – 8.5 
|-
|
'''STAGNATION'''
|

The presence of stagnant water in distribution systems increases the risk of Legionella contamination 
|-
|
'''WATER TREATMENT'''
|

The type of water treatment used may affect the numbers of legionellae present in a distribution system 
|-
|
'''DISINFECTANTS'''
|

The type, concentration and persistence of residual disinfectants in the system may affect the numbers and types of legionellae present 
|-
|
'''CHEMICAL PARAMETERS'''
|

The presence of organic carbon and certain metals like zinc and copper may influence the risk of Legionella contamination 
|-
|
'''RELATIVE HUMIDITY'''
|

Legionellae survive best at 65% relative humidity (RH) and are least stable below 55% RH
|-
|
'''SLIME, ALGAE AND PROTOZOA'''
|

Amoebae, cyanobacteria and flavobacteria have been associated with the growth of legionellae in water distribution systems
 
|-
|
'''CORROSION PRODUCTS'''
|

Legionellae numbers are usually highest in sections where corrosion products are present
 
|-
|
'''CONSTRUCTION'''
|

Major construction has been associated with outbreaks of legionellosis.

It is believed that legionellae are released from the soil during excavations from where they can enter the cooling tower of the building, air intakes or water pipes, or may be inhaled directly. Another possibility is that, during construction, nutrients already present in dust and dirt may become more readily available for the organisms. In new buildings, plumbing should be flushed before use. Renovated buildings may contain stagnant water, that should be flushed out before returning the building to normal use.
 
|-
|
'''WATER PRESSURE'''
|

An increase in water pressure may send dirt into a system, providing a food source for the bacteria or may dislodge scale and sediment containing legionellae from pipes.
 
|-
|
'''BIOFILM, SCALE AND SEDIMENT'''
|

In hot water systems the concentrations of legionellae are usually highest within biofilms and at the openings of water outlets. Biofilms are widespread in nature, and on most man-made surfaces when submerged in water.

Legionellae are not only able to survive in biofilms, but can proliferate and attach to susceptible hosts like protozoa, depending on the type of material on which the biofilm is formed. For example:

· Legionellae have been found in biofilms forming on plastic surfaces in water piping systems. At a temperature of 40° they were shown to account for approximately 50% of the total biofilm flora;

· Legionellae are less likely to be present on copper surfaces because copper generally do not support biofouling. If present, the bacteria are usually found in small numbers;

· Metal plumbing components and associated corrosion products provide iron and other metals needed for Legionella, thereby supporting their survival and growth.

Sediment and scale assists in the growth of supporting organisms and free-living protozoa, increasing the risk of contamination by legionellae. For this reason, its presence often indicates a possibility of Legionella contamination.

Algal slime also provides a stable habitat for their survival and multiplication.
 
|}
'''Disinfectants'''
After disinfection, municipal water supplies usually travel several kilometers before it reaches the point of use. During this course, disinfectant residuals diminish and there is increasing exposure to potentially biofilm-contaminated piping. Although municipal water systems are required to be disinfected at their points of distribution to conform to existing standards for bacterial disinfection, these standards are based upon the absence of coliform bacteria and do not include any specific testing requirements for Legionella.

====='''Transmission'''=====
After growth and amplification of legionellae to potentially infectious levels, the next requirement in the chain of infection is to achieve transmission of the bacteria to a susceptible host. Modern technology like cooling towers used to recirculate water for air-conditioning and humidifying purposes and other ventilation systems can cause the formation and distribution of aerosols through which the organisms can spread. Transmission can also occur through direct installation, aspiration or ingestion (Table [[Legionella Control#Dissemination of Legionella bacteria|Dissemination of Legionella bacteria]]).
{| class="wikitable"
|+'''Dissemination of Legionella bacteria'''
|
'''AEROSOLISATION'''
|

The most widely accepted theory for Legionella transmission is that the organism is aerosolised from a water distribution system and is inhaled as droplets of respirable size. Aerosolisation may affect persons outside as well as inside a building.
 
|-
|
'''DIRECT INSTALLATION'''
|

Respiratory therapy devices have the potential to disseminate legionellae by delivering gases at high temperatures and volumes, and by generating concentrated aerosols, enabling them to bypass the normal defence mechanisms of the respiratory system.
 
|-
|
'''INGESTION'''
|

The fact that diarrhoea is one of the symptoms of Legionnaires’ disease suggests the gastro-intestinal tract as the source in some cases. After infection via this route, the bacteria may spread to the respiratory tract, thereby causing Legionnaires’ disease.
 
|-
|
'''ASPIRATION'''
|

Another well documented mode of transmission that effectively gets bacteria into the lungs is aspiration (a “choking process” that often occur during drinking, swallowing or dlearing the throat, and during respiratory therapy). Evidence suggests that it may be a more common mode for Legionella dissemination than previously believed although it has not been widely described in the literature.<blockquote>

'''REMEMBER!'''

Never presume that you cannot get Legionnaires’ disease

from drinking water containing Legionella.</blockquote>

|}
[[File:Influence of temperature on Legionella growth (Freije 1996).png|alt=Influence of temperature on Legionella growth|none|thumb|604x604px|Influence of temperature on Legionella growth <ref name=":0" />]]

====='''INFECTION AND HOST SUSCEPTIBILITY'''=====
Infections caused by Legionella species are collectively known as ''legionellosis'' and include Legionnaires’ disease and Pontiac fever. Subclinical (asymptomatic) infections have been reported. Legionellosis occurs worldwide, in people of all ages and race groups, with no evidence of person-to-person spread of infection. It is most common in summer and autumn months. The incidence of legionellosis varies from country to country and from region to region. Recently, an increase in the worldwide incidence of reported legionellosis cases has become evident. This may be explained by the availability of improved diagnostic and testing methods, increased awareness of the symptoms and improved surveillance. However legionellosis, especially sporadic cases, is still not always reported to public health authorities, making it difficult to estimate its true incidence.

The mode of transmission, inoculum size, particle size and host susceptibility influence the severity of infection. Approximately half of the currently known Legionella species are implicated in disease, but ''pneumophila'' is still considered to be the causative agent in about 80% of diagnosed cases. However, this picture might change as the number of available diagnostic tests increases – it is thus important to regard all legionellae a potentially pathogenic until proven otherwise.

==Section 3==
===LEGIONELLA INFECTIONS===
Infections caused by Legionella species are collectively known as legionellosis and include Legionnaires’ disease and Pontiac fever.1,2 Subclinical infections have been reported. Legionella infections occur worldwide in people of all ages and race groups with no evidence of person-to-person spread of infection.3,4

===LEGIONNAIRES’ DISEASE===
Legionnaires’ disease (LD) is a severe multisystem disease with pneumonia as the most predominant clinical finding. Clinical features are similar to those of other pneumonias, making it difficult to diagnose.5,6 Symptoms range from a mild cough and slight fever to a coma with widespread pulmonary infiltrates and multisystem failure. Survivors usually recover completely although lung fibrosis and neurological abnormalities may persist in some cases. LD has a low attack rate but the mortality rate is high.

Legionnaires’ disease outbreaks occur frequently all over the world. In the United States, Legionnaires’ disease is considered to be fairly common and legionellae are among the top three causes of sporadic, community-acquired pneumonia. However, many cases are still not reported, as Legionnaires’ disease is difficult to distinguish from other forms of pneumonia. Although only approximately 1,000 cases are reported to the Centers for Disease Control and Prevention (CDC), it is estimated that over 25,000 cases occur every year, causing more than 4,000 deaths.

Despite this, only one outbreak has been reported in South Africa to date. However, previous South African studies indicated antibody levels to L pneumophila in 65% of healthy blood donors, 36% of healthy mineworkers, 10% of healthy factory workers and 16% of hospitalised pneumonia patients.7,8 One study reported seroconverion to L.

pneumophila in 9% of patients hospitalised between 1987 and 1988 with symptoms of community-acquired pneumonia.9

 
[[File:Hillside figure 3.1.jpg|thumb|420x420px|Figure 3.1 Legionella pathology|alt=|center]]

Figure 3.1 Legionella pathology
===RISK FACTORS===
In order for LD to occur, the host must be susceptible to infection. Older people (above 50 years of age) are more commonly infected. Men are more likely to be infected (ratio 3:1) but the racial distribution is usually consistent with that of the population involved.'''10'''

Table 3.1 lists the most common risk factors.
{| class="wikitable"
|+
!
!Table 3.1 Risk factors for development of Legionnaires’ disease
|-
|'''Patient demographics'''
|Smoking
Chronic pulmonary disease

Immunosuppression

Renal transplantation

Renal dialysis

Alcohol ingestion

Age > 50 years

Male
|-
|'''Environmental risks'''
|Exposure to construction activities
Exposure to air conditioning systems

Exposure to home air conditioning

Travelling and accommodation in hotels

Potable water

Hospitalization
|}
Source: Winn 1984 10

[[File:FIGURE 3.2 HISTOLOGY.jpg|center|thumb|500x500px|Figure 3.2 Risk Factors]]

===SYMPTOMS===
Legionnaires’ disease presents with a broad spectrum of symptoms, ranging from mild cough and low fever to stupor, respiratory and multi organ failure. Pneumonia is the predominant clinical finding. Early symptoms are mainly non-specific and include fever, malaise, myalgias, anorexia and headache.6,11 The temperature often exceeds 40°C and the patient may present with a slightly productive cough. Chest pain, occasionally pleuritic, can be prominent and when coupled with hemoptysis, may mistakenly suggest pulmonary emboli. Gastrointestinal symptoms (watery stools) are prominent, especially diarrhoea, which occurs in 20-40% of cases. Relative bradycardia has been over-emphasised as a diagnostic finding but is often seen in elderly patients with advanced pneumonia. Hyponatremia (serum sodium concentration ≥ 130 mmol/l) occurs more frequently in Legionnaires’ disease than in other pneumonias.

Extrapulmonary Legionnaires’ disease is rare but the clinical manifestations are often dramatic. These infections can easily be overlooked since the degree of suspicion is generally low in these cases. Legionella has been implicated in cases of sinusitis, cellulitis, pancreatitis, peritonitis and pyelonephritis. The most common extrapulmonary site of infection is the heart. There have been numerous reports of myocarditis, pericarditis, postcardiotomy syndrome and prosthetic valve endocarditis. In most cases there is no pneumonia symptoms present. Wound infections have also been reported.11

===INCUBATION PERIOD===
LD has an incubation period (the time it takes for symptoms to appear after exposure) of 2 – 10 days. The onset of symptoms may be sudden or gradual.

===DIAGNOSIS===
There are no reliable distinguishing clinical features to distinguish LD from pneumonia caused by other etiologic agents. However, there are some clinical clues to assist in the diagnosis (Table 3.2).6
{| class="wikitable"
|+
!Table 3.2 Clinical clues to Legionnaires’ disease
!
|-
|'''CLUE'''
|'''EXAMPLE'''
|-
|'''PATIENT HISTORY AND PHYSICAL EXAMINATION'''
|
|-
|Presence of an epidemic or documented source of infection
|Family, friends or associates with similar infection and exposure
|-
|Prominent neurologic or gastrointestinal symptoms
|Pneumonia with confusion, nausea and vomiting
|-
|Non-response to aminoglycosides or beta-lactam antibiotics
|Worsening condition after 5 days on antibiotics
|-
|'''LABORATORY RESULTS OF PATIENT'''
|
|-
|Gram stain of sputum with many neutrophils but no bacteria
|Laboratory reports showing many neutrophils and few normal flora or no bacteria
|-
|Nodular peripheral infiltrates in chest radiographs
|Progression of unilateral opacities to bilateral nodular infiltrates over several days
|}

It is important to remember that a clinical diagnosis of LD always has to be confirmed with specialised laboratory tests. As not all laboratories are equipped to perform these tests routinely, the tests have to be specifically requested by the physician. Table 3.3 highlights some of the most commonly used laboratory tests.12

*'''Culture''' of Legionella organisms from clinical samples is still the gold standard for diagnosing LD. The technique is highly specific, provided appropirate samples are used, and about 1.5 to 3 times more sensitive than immunofluorescence. Transtracheal aspirates are best for culture, but sputum, bronchial aspirates, pleural exudates, lung biopsies as well as wound swabs and even autopsy material have been used successfully.11 Disadvantages of the culturing of legionellae for diagnostic purposes include possible inhibition by non-legionellae organisms present in the sample, slow growth and difficulties in distinguishing legionellae from other organisms on solid media. These factors must be taken into account when choosing a laboratory to test clinical samples for LD.

*'''Immunofluorescence''' is useful to detect antigens (direct immunofluorescence) or antibodies (indirect immunofluorescence) in clinical samples in cases where culture is not possible. Cross reactions with organisms other than Legionella in the direct immunofluorescence (DFA) test may cause false positive results, making accurate interpretation of the results essential.11,13 Indirect immunofluorescence (IFA) is the most specific of the currently available serological tests for LD. It is reproducible, sensitive and specific for the diagnosis of especially L. pneumophila infections, but may be affected by several factors, including the method of antigen preparation, method of antigen fixation during preparation of the reagent, the class of immunoglobulin it is designed to detect and strain differences.14,15

*'''The Legionella Urinary Antigen test5''' is a relatively inexpensive and rapid diagnostic test, but only detects infections caused by L pneumophila Serogroup 1. The test is commercially available as a radioimmunoassay (RIA) or an enzyme linked immunosorbent assay (ELISA). An advantage of this test is the relative ease with which urine samples can be obtained, especially in patients with a non-productive cough. Legionella antigens may persist in the urine of some patients for as long as one year.

*'''Serological tests''' are useful for epidemiologic studies but less valuable for physicians. Diagnosis by serology is based on a fourfold rise in antibody titre to ≥ 1:128 in paired samples (from the acute and convalescent stage of disease).13,15 However, the antibody response may not be detectable until 1-3 months after onset of illness. Single titres of ≥1:256 during convalescence in pneumonia patients is suggestive of legionellosis. Antibody screening should include both IgG and IgM because some patients may only have an IgM response.5

*Assays based on the '''polymerase chain reaction (PCR)''' have been used to detect legionellae in urine, broncho-alveolar lavage fluid and sputum. These tests are highly specific but not more sensitive than culture and are much more expensive to perform. Limitations of PCR tests include the possible presence of certain “PCR inhibitors” in sputum and blood samples. The major advantage of PCR is the rapidity of the test and the ability to detect species other than L pneumophila. PCR is not used routinely for the clinical diagnosis of LD.

{| class="wikitable"
|+
!Table 3.3 Sensitivity and specificity of laboratory tests for the diagnosis of Legionnaires’ disease
!
!
|-
|'''TEST'''
|'''SENSITIVITY (%)'''
|'''SPECIFICITY (%)'''
|-
|Culture from clinical samples
|80
|100
|-
|Direct immunofluorescence (DFA)
|33-70
|96-99
|-
|Indirect immunofluorescence (IFA)
|40-60
|96-99
|-
|Urinary antigen detection
|70
|100
|}
Source: Stout and Yu, 1997 '''WHAT TO TAKE INTO ACCOUNT WHEN INTERPRETING LABORATORY RESULTS'''

*Both IgM and IgG should be measured simultaneously.
*Diagnostic IgM titres will provide an earlier diagnosis than IgG because they indicate a primary immune response.
*Results obtained by the IFA should always be interpreted in conjunction with the clinical presentation of the disease.
*Titres below the diagnostic level together with clinical manifestations may be useful for early provisional diagnosis of Legionnaires’ disease; but diagnosis by IFA is usually retrospective.
*The interpretation of the IFA should take into account the variation in the time of appearance of antibodies, the types of antibodies produced and the length of time the antibodies are detectable in sporadic cases, as well as the prevalence of antibodies in the population from which the patient comes.
*The type of reagents used for IFA tests may influence the results: ether-killed, formalin-killed or heat-killed antigens vary in sensitivity and specificity and this should be taken into account in the interpretation.
*False negative results may be reported because a long time is needed for seroconversion to occur and not all species and serogroups are detectable by this method.
*Seroconversion (a fourfold rise in titre to at least 1:128) is considered as a presumptive positive result.
*A single titre of 1:256 or higher is regarded as a presumptive positive result.
*Serological results should preferably be confirmed by culture.
*In communities with low antibody prevalence, a single titre of 1:128 may be diagnostic and where the prevalence is high, a single titre of 1:256 may still provide only presumptive evidence of infection.
*Low titres usually indicate past infections.
*When titres to multiple antigens are raised, the titre that is fourfold higher than the others is considered to be diagnostic.
*In epidemiological studies diagnostic titres are usually one twofold dilution higher than for sporadic cases.

===HISTOLOGY===
Pulmonary lesions usually consist of a mixture of neutrophils and macrophages, fibrin, proteinaceous material and red blood cells. Neutrophils and macrophages are often present in the centre of a lesion with mainly macrophages around the periphery.

Intracellular bacteria are present in both neutrophils and macrophages. Further away from the site of acute inflammation, bacteria are mainly seen inside the macrophages.10

 
[[File:FIGURE 3.3.jpg|center|thumb|500x500px|Figure 3.3 Histological section of lung of Legionnaires disease patient]]
 

===CHEST RADIOGRAPHS===
Radiographic features in Legionnaires’ disease are mostly non-specific, and absent in Pontiac fever. Abnormalities occur from the third day post infection in most Legionnaires’ disease patients and usually do not correlate well with the severity of illness.11 However, the abnormalities correlate with the presence of the Legionella bacterium in sputum. The time required to show clearing of infiltrates on radiographs is variable and may range from 1-4 months. Some patients show diffuse alveolar damage. In the majority of patients with Legionnaires’ disease:

*Initial involvement is unilateral, predominantly in the lower lobe
*Bilateral involvement has been described
*Initial densities are poorly marginated, homogenous, rounded, occur either on the periphery or in the centre of the lung and may be mistaken for pulmonary infarction
*Pulmonary densities enlarge during later stages of disease
*Pulmonary densities have a typical ground glass appearance or dense consolidation
*Total opacification of the lung may occur
*Pleural effusions are present in 24-63% of cases caused by L pneumophila
*Pleural effusions are uncommon in L micdadei infections
*Hilar adenopathy seldom occurs
*Cavitation may occur in immunocompromised patients
*Cavitation rarely occurs in L micdadei infections

Figure 3.4 Chest radiograph of Legionnaires’ disease patient

===TREATMENT===
Treatment of LD requires the use of antibiotics. However, many antibiotics effective against other bacterial pneumonias are ineffective against Legionella as these drugs do not penetrate the pulmonary cells (alveolar macrophages) where infectious Legionella bacteria thrive.

Erythromycin was historically the drug of choice for the treatment of Legionnaires’ disease, but the newer macrolides (azithromycin) and quinolones (ciprofloxacin, levofloxacin, moxifloxacin, gemifloxacin, trovofloxacin have superior in vitro activity and greater intracellular and lung-tissue penetration.12 Other agents that have been shown to be effective include tetracycline, doxycycline, minocycline, trimethoprim- sulfamethoxazole.12 Rifampin is recommended as part of combination therapy with a macrolide or a quinolone for patients who are severely ill. The total duration of therapy is usually 10-14 days; however a 21-day course may be needed for immuno-compromised patients or those with extensive evidence of disease on chest radiographs.12

When LD patients are treated with appropriate antibiotics near the onset of disease, the prognosis is usually very good, especially if there is no underlying illness compromising the immune system. For patients with compromised immune systems, including transplant patients, any delay of appropriate treatment may result in complications, prolonged hospitalisation and death. However after successful treatment and hospital discharge, many patients still experience fatigue, loss of energy and difficulty concentrating. These symptoms may persist for several months, but complete recovery usually occurs within one year.

===PONTIAC FEVER===
Pontiac fever is an acute, self-limiting, flu-like illness without symptoms of pneumonia. The first outbreak of Pontiac fever was reported in Pontiac, Michigan, in 1968.16

It is characterised by high fever, chills, myalgia and malaise but without the pneumonia or cough typical of Legionnaires’ disease. Some authors suggest that it is a hypersensitivity pneumonitis, caused either by infection with a free-living amoeba called ''Acanthamoeba'' filled with legionellae or as a result of a toxic reaction to the organism. The incubation period is short, ranging from 1 – 3 days, and the attack rate high, exceeding 90% in some cases. The fatality rate is low.

Pontiac fever symptoms usually resolve spontaneously within one week, only symptomatic treatment is needed and the chest radiograph is clear. There is no evidence of secondary spread of the infection in Pontiac fever. Diagnosis can only be made by seroconversion, which may be delayed for up to 6 weeks after onset of symptoms. Cases of PF have been linked to ''L pneumophila, L feelei and L anisa''. Complete recovery usually occurs in 2 – 5 days without medical attention.

==Acknowledgements==
Delene Bartie (CB Scientific)- 2023

==References Chapter 3==

#Dowling JN, McDaevitt DA, Pasculle AW. Isolation and preliminary characterization of erythromycin-resistant variants of Legionella micdadei and Legionella pneumophila. Agents Chemother. 1985, 27 (2): 272-274.
#MacFarlane JT, Miller AC, Smith WH, Morris AH, Rose DH. Comparative radiographic features of community acquired Legionnaires’ disease, pneumococcal pneumonia, Mycoplasma pneumonia and psittacosis. Thorax 1984, 39: 28-33.
#Boldur I, Beer S, Kazak R, Kahana H, Kannai Y. Predisposition of the asthmatic child to legionellosis? Isr. J. Med. Sci 1986, 22 (10): 733-736.
#Kurtz JB. Legionella pneumophila. Am. J. Occup. Hyg. 1988, 32 (1): 59-61.
#Shapiro M. Unusual epidemiologic and clinical manifestations of legionellosis: a review. Isr. J. Med. Sci. 1986, 22 (10): 724-727.
#Yu VL. Legionella pneumophila (Legionnaires’ disease). In: Mandell, Douglas and Bennet (eds). Principles and practice of infectious disease. 1990, Third Edition, Churchill Livingstone.
#Ratshikhopha ME, Klugman KP, Koornhof HJ. An evaluation of two indirect fluorescent antibody tests for the diagnosis of Legionnaires’ disease in South Africa. South African Med. J. 1990, 77: 392-395.
#Bartie C and Klugman KP. Exposures to Legionella pneumophila and Chlamydia pneumoniae in South African mine workers. Int. J. Occup. Environ. Health 1997, 3: 120-127.
#Maartens G, Lewis SJ, de Goveia C, Bartie C, Roditi D, Klugman KP. “Atypical” bacteria are a common cause of community acquired pneumonia in hospitalised adults. South African Med. J. 1994, 84: 678-682.
#Winn 1991
#Roig J, Aguilar X, Ruiz J, Domingo C, Mesalles E, Manterola J, Morera J. Comparative study of Legionella pneumophila and other nosocomial-acquired pneumonias. CHEST 1991, 99: 344-350.
#Stout JE, Yu VL. Legionellosis. New Engl. J. Med. 1997, 682-687.
#Ruf B, Schürman D, Horbach I, Fehrenbach FJ, Pohle HD. Prevalence and diagnosis of Legionella pneumonia: a 3-year prospective study with emphasis on application of urinary antigen detection. J. Inf. Dis. 1990, 162: 1341-1348.
#Harrison TG, Dournon E, Taylor AG. Evaluation of sensitivity of two serological tests for diagnosing pneumonia caused by Legionella pneumophila serogroup 1. J. Clin. Pathol. 1987, 40: 77-82.
#Pastoris MC, Ciarrochi S, Di Capula A, Temperanza AM. Comparison of phenol- and heat-killed antigens in the indirect immunofluorescence test for serodiagnosis of Legionella pneumophila serogroup 1 antigens. J. Clin. Microbiol. 1984, 20 (4): 780-783.
#Kaufmann AF, McDade JE, Patton CM, Bennett JV, Skalyi P, Feeley C, Anderson DC, Potter ME, Newhouse VF, Gregg MB, Brachman PS. Pontiac fever: isolation of the etiologic agent (Legionella pneumophila) and demonstration of its mode of transmission. Am. J. Epid. 1981, 114 (3): 337-347.
#Dennis PJ (1993). Potable water systems: insights into control. In: Barbaree JM, Breiman RF and Dufour AP (eds). Legionella: Current status and emerging perspectives. American Society for Microbiology, Washington DC. Pp 223-225.
#Colbourne JS and Dennis PJ (1985). Distribution and persistence of Legionella in water systems. ''Microbiol. Sc.'' '''2''': 40-43.
#Muraca PW, Stout JE, Yu VL and Yee YC (1988). Mode of transmission of ''Legionella pneumophila''. A critical review. ''Am. J. Hyg. Assoc.'' '''49''': 584-590.
#Yamamoto H, Sugiura M, Kusunoki S, Ezaki T, Ikedo M and Yabuuchi E (1992). Factors stimulating propagation of legionellae in cooling tower water. ''Appl. Environ. Microbiol.'' '''58''': 1394-1397
#[[Legionella Control#cite%20ref-:0%205-0|Jump up to:5.0]] [[Legionella Control#cite%20ref-:0%205-1|5.1]] Freije MR (1996). Legionella control in healthcare facilities: A guide for minimising risk. HC Information Resources, Inc. United States of America. P 8
#MarrieTJ, Haldane D, Bezanson G and Peppard R (1992). Each water outlet is a unique ecological niche for ''Legionella pneumophila''. ''Epid. Infect.'' '''108''': 264-270

[[Category:Legionella Control]]
[[Category:Infection Prevention and Control]]
[[Category:Water Distributions Systems]]

Legionella Control

2020-10-22T13:19:08Z

Tmojanaga: /* 3.4 DIAGNOSIS */

{{Stub}}
{{Anchor|Section1}}
==Section 1==
{{Expand}}

==Section 2==

==='''THE CHAIN OF INFECTION'''===
The mere presence of legionellae in a water distribution system does not necessarily imply a human health risk. For human infection to occur, certain conditions are necessary. These conditions are referred to as the “chain of infection” consisting of six links. All the links have to be present for disease to occur ([[#Legionella-Chain_of_Infection|Diagram: Chain of infection]] ). The first link, the pathogen, was discussed in [[#Section1|Section 1]].

{{Anchor|Legionella-Chain_of_Infection}}
[[File:Chain of infection.png|alt=Chain of infection|none|thumb|Chain of infection|450x450px]]

==='''SOURCES AND RESERVOIRS'''===
Legionellae are natural inhabitants of water, found a wide range of habitats. They are ubiquitous in streams, lakes and rivers. They also survive in dust, soil and mud. In fact, one of the species, ''Legionella longbeacheae'', is so often isolated from potting soil in Australia that soil has been suggested as the natural habitat of this particular species.<ref>Dennis PJ (1993). Potable water systems: insights into control. In: Barbaree JM, Breiman RF and Dufour AP (eds). Legionella: Current status and emerging perspectives. American Society for Microbiology, Washington DC. Pp 223-225.</ref>

{{Anchor|Natural sources of Legionella}}
[[File:Natural sources of Legionella.png|alt=Natural sources of Legionella|none|thumb|Chain of infection|450x450px]]

Legionellae from these natural environments can be transmitted to man-made water systems by various means. For example, from raw water, during water treatment, as part of post-treatment after-growths within water distribution systems, during building and construction activities and during plumbing repair.<ref>Colbourne JS and Dennis PJ (1985). Distribution and persistence of Legionella in water systems. ''Microbiol. Sc.'' '''2''': 40-43.</ref>

Once established, they can persist in the water supply for long periods of time and are difficult to eradicate. Therefore, their presence must be considered in all aspects of the design, operation and maintenance of buildings. For this to be effective, cooperation between engineers, occupational health practitioners and microbiologists is essential.

Figure 2.3 Man-made sources of Legionella

=====Water sources that provide optimal conditions for Legionella growth can be separated into those containing “non-potable” and those that contain “potable” water. '''Non-potable water distribution systems'''=====

Heat rejection devices like cooling towers, evaporative condensers and HVAC (heating, ventilation and air-conditioning) systems are often implicated as sources of legionellosis. They contain reservoirs filled with warm, recirculating water that makes them ideal for the growth, amplification and dissemination of micro organisms (including Legionella). In a typical water-cooled system air in induced through or blown over, packing material down which water, circulating from a pond under the packing, is allowed to fall by gravity, producing a large wetted surface that cools the falling water.

The constant fall of water through the tower, the large area of the basin, fill, pipes and heat exchanger, the warm temperature of the water, the high relative humidity and high organic content within these devices provide conditions that favour contamination by algae, protozoa, fungi and bacteria. The risk is increased further by the open nature of the systems, excessive aeration and the constant addition of fresh water to make up for water lost through evaporation.

In systems that are not regularly cleaned, sludge accumulates in the reservoir and slime adheres to water covered surfaces, resulting in the presence of large concentrations of micro-organisms, including legionellae, on these surfaces. In addition, water temperatures below 60°C, the age and configuration of the system, the pH of the water and the presence of certain metals may also increase the risk of contamination.

Water derived from municipal supplies but subsequently stored in cisterns, or conditioned prior to heating, is considered non-potable due to the deterioration in chemical and bacteriological quality during storage. Colonisation of such non-potable sources inside large buildings, such as hotels, factories or hospitals, may be a major cause of legionellosis.<ref>Muraca PW, Stout JE, Yu VL and Yee YC (1988). Mode of transmission of ''Legionella pneumophila''. A critical review. ''Am. J. Hyg. Assoc.'' '''49''': 584-590.</ref><ref>Yamamoto H, Sugiura M, Kusunoki S, Ezaki T, Ikedo M and Yabuuchi E (1992). Factors stimulating propagation of legionellae in cooling tower water. ''Appl. Environ. Microbiol.'' '''58''': 1394-1397</ref><ref name=":0">Freije MR (1996). Legionella control in healthcare facilities: A guide for minimising risk. HC Information Resources, Inc. United States of America. P 8</ref>

====='''Potable (domestic) water distribution systems'''=====
Legionellae are often present in potable water supplies, especially in the hot water sections of these systems. The organisms may enter potable water supplies from the main source, even from municipal water, and survive standard treatment protocols because most municipal water systems are not routinely screened for the presence of legionellae and the organisms are chlorine tolerant. Once inside the system, they find a suitable environment to multiply and are usually very difficult to eradicate.

Legionella levels can rise from very low to very high within short periods of time. The factors that give rise to these fluctuations are not well understood and often very hard to determine. These factors include the age and configuration of the pipes, the degree of scaling and sediment and the potential for biofilm formation within the system increase the risk of contamination. Water temperatures of 25 – 42°C, stagnation and the presence of certain free-living amoebae capable of supporting the intracellular growth of legionellae are often mentioned as amplifying factors in published reports. The biofilm and scale that form on surfaces in water distribution systems provide nutrients for legionellae and protect them from hot water and disinfectants. Some materials used in these systems, for example neoprene washers, are more readily colonised than others (See [[Legionella Control#Materials used in the construction of potable water lines and fixtures|Table]]). Building location may also play a role in the colonisation of potable water with legionellae.

Hot water tanks are often colonised with legionellae, especially at the bottom where a warm zone may develop and scale and sediment accumulate.<ref>MarrieTJ, Haldane D, Bezanson G and Peppard R (1992). Each water outlet is a unique ecological niche for ''Legionella pneumophila''. ''Epid. Infect.'' '''108''': 264-270</ref> Hot water piping, especially dead-legs, presents an additional risk as legionellae thrive in stagnant water.

====='''Soil'''=====
Outdoors, the soil may be contaminated through contact with Legionella-polluted water and become a source of airborne bacteria during earth moving operations, such as construction work.
{| class="wikitable"
|+{{Anchor|Materials used in the construction of potable water lines and fixtures}}'''Materials used in the construction of potable water lines and fixtures'''
|
'''Very good'''
|
Copper
|-
|
'''Good'''
|

Neoprene

Other synthetic materials
|-
|
'''Reasonable'''
|
Steel
|-
|
'''Not recommended'''
|
Rubber

Plastics
|}

===='''Amplification'''====
Legionellae are usually present in low numbers in natural sources. However, certain factors present in man-made reservoirs can promote Legionella growth and amplification. To improve our understanding of Legionella, its potential to cause disease and how to better control the organisms in water systems, we must understand these conditions. The most important factors amplifying Legionella numbers in man-made reservoirs are listed in the table [[Legionella Control#Amplifying factors for Legionella in man-made sources and reservoirs.|Amplifying factors for Legionella in man-made sources and reservoirs.]]
'''Remember'''
Temperature data is usually based on laboratory studies and is not from actual system (piping) studies, which makes it even less reliable to use for Legionella control. System temperature on its own should therefore not be relied upon for Legionella control, because the so-called “system temperature” rarely indicates one uniform temperature throughout the entire system. Therefore, maintaining the system temperature does not guarantee Legionella control. Also, in plumbing systems, especially larger and/or more complex piping systems, legionellae have been shown to survive at even higher temperatures due to biofilm, dead-legs, and other complexities. It has been suggested that potable water systems be operated at temperatures as high as possible but take into account the risk of scalding injuries and energy conservation requirements.
{| class="wikitable"
|+{{Anchor|Amplifying factors for Legionella in man-made sources and reservoirs}}'''Amplifying factors for Legionella in man-made sources and reservoirs'''
|
'''TEMPERATURE'''
|

Legionellae can survive over a wide range of temperatures (20 – 60°C) with an optimum growth temperature of 37 – 45°C as illustrated in the figure [[Legionella Control#Natural sources of Legionella|Natural sources of Legionella]] 
|-
|
'''pH'''
|

Legionellae can survive and multiply at a pH of 5.0 – 8.5 
|-
|
'''STAGNATION'''
|

The presence of stagnant water in distribution systems increases the risk of Legionella contamination 
|-
|
'''WATER TREATMENT'''
|

The type of water treatment used may affect the numbers of legionellae present in a distribution system 
|-
|
'''DISINFECTANTS'''
|

The type, concentration and persistence of residual disinfectants in the system may affect the numbers and types of legionellae present 
|-
|
'''CHEMICAL PARAMETERS'''
|

The presence of organic carbon and certain metals like zinc and copper may influence the risk of Legionella contamination 
|-
|
'''RELATIVE HUMIDITY'''
|

Legionellae survive best at 65% relative humidity (RH) and are least stable below 55% RH
|-
|
'''SLIME, ALGAE AND PROTOZOA'''
|

Amoebae, cyanobacteria and flavobacteria have been associated with the growth of legionellae in water distribution systems
 
|-
|
'''CORROSION PRODUCTS'''
|

Legionellae numbers are usually highest in sections where corrosion products are present
 
|-
|
'''CONSTRUCTION'''
|

Major construction has been associated with outbreaks of legionellosis.

It is believed that legionellae are released from the soil during excavations from where they can enter the cooling tower of the building, air intakes or water pipes, or may be inhaled directly. Another possibility is that, during construction, nutrients already present in dust and dirt may become more readily available for the organisms. In new buildings, plumbing should be flushed before use. Renovated buildings may contain stagnant water, that should be flushed out before returning the building to normal use.
 
|-
|
'''WATER PRESSURE'''
|

An increase in water pressure may send dirt into a system, providing a food source for the bacteria or may dislodge scale and sediment containing legionellae from pipes.
 
|-
|
'''BIOFILM, SCALE AND SEDIMENT'''
|

In hot water systems the concentrations of legionellae are usually highest within biofilms and at the openings of water outlets. Biofilms are widespread in nature, and on most man-made surfaces when submerged in water.

Legionellae are not only able to survive in biofilms, but can proliferate and attach to susceptible hosts like protozoa, depending on the type of material on which the biofilm is formed. For example:

· Legionellae have been found in biofilms forming on plastic surfaces in water piping systems. At a temperature of 40° they were shown to account for approximately 50% of the total biofilm flora;

· Legionellae are less likely to be present on copper surfaces because copper generally do not support biofouling. If present, the bacteria are usually found in small numbers;

· Metal plumbing components and associated corrosion products provide iron and other metals needed for Legionella, thereby supporting their survival and growth.

Sediment and scale assists in the growth of supporting organisms and free-living protozoa, increasing the risk of contamination by legionellae. For this reason, its presence often indicates a possibility of Legionella contamination.

Algal slime also provides a stable habitat for their survival and multiplication.
 
|}
'''Disinfectants'''
After disinfection, municipal water supplies usually travel several kilometers before it reaches the point of use. During this course, disinfectant residuals diminish and there is increasing exposure to potentially biofilm-contaminated piping. Although municipal water systems are required to be disinfected at their points of distribution to conform to existing standards for bacterial disinfection, these standards are based upon the absence of coliform bacteria and do not include any specific testing requirements for Legionella.

====='''Transmission'''=====
After growth and amplification of legionellae to potentially infectious levels, the next requirement in the chain of infection is to achieve transmission of the bacteria to a susceptible host. Modern technology like cooling towers used to recirculate water for air-conditioning and humidifying purposes and other ventilation systems can cause the formation and distribution of aerosols through which the organisms can spread. Transmission can also occur through direct installation, aspiration or ingestion (Table [[Legionella Control#Dissemination of Legionella bacteria|Dissemination of Legionella bacteria]]).
{| class="wikitable"
|+'''Dissemination of Legionella bacteria'''
|
'''AEROSOLISATION'''
|

The most widely accepted theory for Legionella transmission is that the organism is aerosolised from a water distribution system and is inhaled as droplets of respirable size. Aerosolisation may affect persons outside as well as inside a building.
 
|-
|
'''DIRECT INSTALLATION'''
|

Respiratory therapy devices have the potential to disseminate legionellae by delivering gases at high temperatures and volumes, and by generating concentrated aerosols, enabling them to bypass the normal defence mechanisms of the respiratory system.
 
|-
|
'''INGESTION'''
|

The fact that diarrhoea is one of the symptoms of Legionnaires’ disease suggests the gastro-intestinal tract as the source in some cases. After infection via this route, the bacteria may spread to the respiratory tract, thereby causing Legionnaires’ disease.
 
|-
|
'''ASPIRATION'''
|

Another well documented mode of transmission that effectively gets bacteria into the lungs is aspiration (a “choking process” that often occur during drinking, swallowing or dlearing the throat, and during respiratory therapy). Evidence suggests that it may be a more common mode for Legionella dissemination than previously believed although it has not been widely described in the literature.<blockquote>

'''REMEMBER!'''

Never presume that you cannot get Legionnaires’ disease

from drinking water containing Legionella.</blockquote>

|}
[[File:Influence of temperature on Legionella growth (Freije 1996).png|alt=Influence of temperature on Legionella growth|none|thumb|604x604px|Influence of temperature on Legionella growth <ref name=":0" />]]

====='''INFECTION AND HOST SUSCEPTIBILITY'''=====
Infections caused by Legionella species are collectively known as ''legionellosis'' and include Legionnaires’ disease and Pontiac fever. Subclinical (asymptomatic) infections have been reported. Legionellosis occurs worldwide, in people of all ages and race groups, with no evidence of person-to-person spread of infection. It is most common in summer and autumn months. The incidence of legionellosis varies from country to country and from region to region. Recently, an increase in the worldwide incidence of reported legionellosis cases has become evident. This may be explained by the availability of improved diagnostic and testing methods, increased awareness of the symptoms and improved surveillance. However legionellosis, especially sporadic cases, is still not always reported to public health authorities, making it difficult to estimate its true incidence.

The mode of transmission, inoculum size, particle size and host susceptibility influence the severity of infection. Approximately half of the currently known Legionella species are implicated in disease, but ''pneumophila'' is still considered to be the causative agent in about 80% of diagnosed cases. However, this picture might change as the number of available diagnostic tests increases – it is thus important to regard all legionellae a potentially pathogenic until proven otherwise.

==Section 3==
===LEGIONELLA INFECTIONS===
Infections caused by Legionella species are collectively known as legionellosis and include Legionnaires’ disease and Pontiac fever.1,2 Subclinical infections have been reported. Legionella infections occur worldwide in people of all ages and race groups with no evidence of person-to-person spread of infection.3,4

===LEGIONNAIRES’ DISEASE===
Legionnaires’ disease (LD) is a severe multisystem disease with pneumonia as the most predominant clinical finding. Clinical features are similar to those of other pneumonias, making it difficult to diagnose.5,6 Symptoms range from a mild cough and slight fever to a coma with widespread pulmonary infiltrates and multisystem failure. Survivors usually recover completely although lung fibrosis and neurological abnormalities may persist in some cases. LD has a low attack rate but the mortality rate is high.

Legionnaires’ disease outbreaks occur frequently all over the world. In the United States, Legionnaires’ disease is considered to be fairly common and legionellae are among the top three causes of sporadic, community-acquired pneumonia. However, many cases are still not reported, as Legionnaires’ disease is difficult to distinguish from other forms of pneumonia. Although only approximately 1,000 cases are reported to the Centers for Disease Control and Prevention (CDC), it is estimated that over 25,000 cases occur every year, causing more than 4,000 deaths.

Despite this, only one outbreak has been reported in South Africa to date. However, previous South African studies indicated antibody levels to L pneumophila in 65% of healthy blood donors, 36% of healthy mineworkers, 10% of healthy factory workers and 16% of hospitalised pneumonia patients.7,8 One study reported seroconverion to L.

pneumophila in 9% of patients hospitalised between 1987 and 1988 with symptoms of community-acquired pneumonia.9

 
[[File:Hillside figure 3.1.jpg|thumb|420x420px|Figure 3.1 Legionella pathology|alt=|center]]

Figure 3.1 Legionella pathology
===3.1 RISK FACTORS===
In order for LD to occur, the host must be susceptible to infection. Older people (above 50 years of age) are more commonly infected. Men are more likely to be infected (ratio 3:1) but the racial distribution is usually consistent with that of the population involved.10

Table 3.1 lists the most common risk factors.
{| class="wikitable"
|+
!
!Table 3.1 Risk factors for development of Legionnaires’ disease
|-
|'''Patient demographics'''
|Smoking
Chronic pulmonary disease

Immunosuppression

Renal transplantation

Renal dialysis

Alcohol ingestion

Age > 50 years

Male
|-
|'''Environmental risks'''
|Exposure to construction activities
Exposure to air conditioning systems

Exposure to home air conditioning

Travelling and accommodation in hotels

Potable water

Hospitalization
|}
Source: Winn 1984 10

[[File:FIGURE 3.2 HISTOLOGY.jpg|center|thumb|500x500px|Figure 3.2 Risk Factors]]

===3.2 SYMPTOMS===
Legionnaires’ disease presents with a broad spectrum of symptoms, ranging from mild cough and low fever to stupor, respiratory and multi organ failure. Pneumonia is the predominant clinical finding. Early symptoms are mainly non-specific and include fever, malaise, myalgias, anorexia and headache.6,11 The temperature often exceeds 40°C and the patient may present with a slightly productive cough. Chest pain, occasionally pleuritic, can be prominent and when coupled with hemoptysis, may mistakenly suggest pulmonary emboli. Gastrointestinal symptoms (watery stools) are prominent, especially diarrhoea, which occurs in 20-40% of cases. Relative bradycardia has been over-emphasised as a diagnostic finding but is often seen in elderly patients with advanced pneumonia. Hyponatremia (serum sodium concentration ≥ 130 mmol/l) occurs more frequently in Legionnaires’ disease than in other pneumonias.

Extrapulmonary Legionnaires’ disease is rare but the clinical manifestations are often dramatic. These infections can easily be overlooked since the degree of suspicion is generally low in these cases. Legionella has been implicated in cases of sinusitis, cellulitis, pancreatitis, peritonitis and pyelonephritis. The most common extrapulmonary site of infection is the heart. There have been numerous reports of myocarditis, pericarditis, postcardiotomy syndrome and prosthetic valve endocarditis. In most cases there is no pneumonia symptoms present. Wound infections have also been reported.11

===3.3 INCUBATION PERIOD===
LD has an incubation period (the time it takes for symptoms to appear after exposure) of 2 – 10 days. The onset of symptoms may be sudden or gradual.

===3.4 DIAGNOSIS===
There are no reliable distinguishing clinical features to distinguish LD from pneumonia caused by other etiologic agents. However, there are some clinical clues to assist in the diagnosis (Table 3.2).6
{| class="wikitable"
|+
!Table 3.2 Clinical clues to Legionnaires’ disease
!
|-
|'''CLUE'''
|'''EXAMPLE'''
|-
|'''PATIENT HISTORY AND PHYSICAL EXAMINATION'''
|
|-
|Presence of an epidemic or documented source of infection
|Family, friends or associates with similar infection and exposure
|-
|Prominent neurologic or gastrointestinal symptoms
|Pneumonia with confusion, nausea and vomiting
|-
|Non-response to aminoglycosides or beta-lactam antibiotics
|Worsening condition after 5 days on antibiotics
|-
|'''LABORATORY RESULTS OF PATIENT'''
|
|-
|Gram stain of sputum with many neutrophils but no bacteria
|Laboratory reports showing many neutrophils and few normal flora or no bacteria
|-
|Nodular peripheral infiltrates in chest radiographs
|Progression of unilateral opacities to bilateral nodular infiltrates over several days
|}

It is important to remember that a clinical diagnosis of LD always has to be confirmed with specialised laboratory tests. As not all laboratories are equipped to perform these tests routinely, the tests have to be specifically requested by the physician. Table 3.3 highlights some of the most commonly used laboratory tests.12

*'''Culture''' of Legionella organisms from clinical samples is still the gold standard for diagnosing LD. The technique is highly specific, provided appropirate samples are used, and about 1.5 to 3 times more sensitive than immunofluorescence. Transtracheal aspirates are best for culture, but sputum, bronchial aspirates, pleural exudates, lung biopsies as well as wound swabs and even autopsy material have been used successfully.11 Disadvantages of the culturing of legionellae for diagnostic purposes include possible inhibition by non-legionellae organisms present in the sample, slow growth and difficulties in distinguishing legionellae from other organisms on solid media. These factors must be taken into account when choosing a laboratory to test clinical samples for LD.

*'''Immunofluorescence''' is useful to detect antigens (direct immunofluorescence) or antibodies (indirect immunofluorescence) in clinical samples in cases where culture is not possible. Cross reactions with organisms other than Legionella in the direct immunofluorescence (DFA) test may cause false positive results, making accurate interpretation of the results essential.11,13 Indirect immunofluorescence (IFA) is the most specific of the currently available serological tests for LD. It is reproducible, sensitive and specific for the diagnosis of especially L. pneumophila infections, but may be affected by several factors, including the method of antigen preparation, method of antigen fixation during preparation of the reagent, the class of immunoglobulin it is designed to detect and strain differences.14,15

*'''The Legionella Urinary Antigen test5''' is a relatively inexpensive and rapid diagnostic test, but only detects infections caused by L pneumophila Serogroup 1. The test is commercially available as a radioimmunoassay (RIA) or an enzyme linked immunosorbent assay (ELISA). An advantage of this test is the relative ease with which urine samples can be obtained, especially in patients with a non-productive cough. Legionella antigens may persist in the urine of some patients for as long as one year.

*'''Serological tests''' are useful for epidemiologic studies but less valuable for physicians. Diagnosis by serology is based on a fourfold rise in antibody titre to ≥ 1:128 in paired samples (from the acute and convalescent stage of disease).13,15 However, the antibody response may not be detectable until 1-3 months after onset of illness. Single titres of ≥1:256 during convalescence in pneumonia patients is suggestive of legionellosis. Antibody screening should include both IgG and IgM because some patients may only have an IgM response.5

*Assays based on the '''polymerase chain reaction (PCR)''' have been used to detect legionellae in urine, broncho-alveolar lavage fluid and sputum. These tests are highly specific but not more sensitive than culture and are much more expensive to perform. Limitations of PCR tests include the possible presence of certain “PCR inhibitors” in sputum and blood samples. The major advantage of PCR is the rapidity of the test and the ability to detect species other than L pneumophila. PCR is not used routinely for the clinical diagnosis of LD.

{| class="wikitable"
|+
!Table 3.3 Sensitivity and specificity of laboratory tests for the diagnosis of Legionnaires’ disease
!
!
|-
|'''TEST'''
|'''SENSITIVITY (%)'''
|'''SPECIFICITY (%)'''
|-
|Culture from clinical samples
|80
|100
|-
|Direct immunofluorescence (DFA)
|33-70
|96-99
|-
|Indirect immunofluorescence (IFA)
|40-60
|96-99
|-
|Urinary antigen detection
|70
|100
|}
Source: Stout and Yu, 1997
 
'''WHAT TO TAKE INTO ACCOUNT WHEN INTERPRETING LABORATORY RESULTS'''

* Both IgM and IgG should be measured simultaneously.
* Diagnostic IgM titres will provide an earlier diagnosis than IgG because they indicate a primary immune response.
* Results obtained by the IFA should always be interpreted in conjunction with the clinical presentation of the disease.
* Titres below the diagnostic level together with clinical manifestations may be useful for early provisional diagnosis of Legionnaires’ disease; but diagnosis by IFA is usually retrospective.
* The interpretation of the IFA should take into account the variation in the time of appearance of antibodies, the types of antibodies produced and the length of time the antibodies are detectable in sporadic cases, as well as the prevalence of antibodies in the population from which the patient comes.
* The type of reagents used for IFA tests may influence the results: ether-killed, formalin-killed or heat-killed antigens vary in sensitivity and specificity and this should be taken into account in the interpretation.
* False negative results may be reported because a long time is needed for seroconversion to occur and not all species and serogroups are detectable by this method.
* Seroconversion (a fourfold rise in titre to at least 1:128) is considered as a presumptive positive result.
* A single titre of 1:256 or higher is regarded as a presumptive positive result.
* Serological results should preferably be confirmed by culture.
* In communities with low antibody prevalence, a single titre of 1:128 may be diagnostic and where the prevalence is high, a single titre of 1:256 may still provide only presumptive evidence of infection.
* Low titres usually indicate past infections.
* When titres to multiple antigens are raised, the titre that is fourfold higher than the others is considered to be diagnostic.
* In epidemiological studies diagnostic titres are usually one twofold dilution higher than for sporadic cases.

===3.5 HISTOLOGY===
Pulmonary lesions usually consist of a mixture of neutrophils and macrophages, fibrin, proteinaceous material and red blood cells. Neutrophils and macrophages are often present in the centre of a lesion with mainly macrophages around the periphery.

Intracellular bacteria are present in both neutrophils and macrophages. Further away from the site of acute inflammation, bacteria are mainly seen inside the macrophages.10

 
[[File:FIGURE 3.3.jpg|center|thumb|500x500px|Figure 3.3 Histological section of lung of Legionnaires disease patient]]
 

===3.6 CHEST RADIOGRAPHS===
Radiographic features in Legionnaires’ disease are mostly non-specific, and absent in Pontiac fever. Abnormalities occur from the third day post infection in most Legionnaires’ disease patients and usually do not correlate well with the severity of illness.11 However, the abnormalities correlate with the presence of the Legionella bacterium in sputum. The time required to show clearing of infiltrates on radiographs is variable and may range from 1-4 months. Some patients show diffuse alveolar damage. In the majority of patients with Legionnaires’ disease:

* Initial involvement is unilateral, predominantly in the lower lobe
* Bilateral involvement has been described
* Initial densities are poorly marginated, homogenous, rounded, occur either on the periphery or in the centre of the lung and may be mistaken for pulmonary infarction
* Pulmonary densities enlarge during later stages of disease
* Pulmonary densities have a typical ground glass appearance or dense consolidation
* Total opacification of the lung may occur
* Pleural effusions are present in 24-63% of cases caused by L pneumophila
* Pleural effusions are uncommon in L micdadei infections
* Hilar adenopathy seldom occurs
* Cavitation may occur in immunocompromised patients
* Cavitation rarely occurs in L micdadei infections

Figure 3.4 Chest radiograph of Legionnaires’ disease patient

===3.7 TREATMENT===
Treatment of LD requires the use of antibiotics. However, many antibiotics effective against other bacterial pneumonias are ineffective against Legionella as these drugs do not penetrate the pulmonary cells (alveolar macrophages) where infectious Legionella bacteria thrive.

Erythromycin was historically the drug of choice for the treatment of Legionnaires’ disease, but the newer macrolides (azithromycin) and quinolones (ciprofloxacin, levofloxacin, moxifloxacin, gemifloxacin, trovofloxacin have superior in vitro activity and greater intracellular and lung-tissue penetration.12 Other agents that have been shown to be effective include tetracycline, doxycycline, minocycline, trimethoprim- sulfamethoxazole.12 Rifampin is recommended as part of combination therapy with a macrolide or a quinolone for patients who are severely ill. The total duration of therapy is usually 10-14 days; however a 21-day course may be needed for immuno-compromised patients or those with extensive evidence of disease on chest radiographs.12

When LD patients are treated with appropriate antibiotics near the onset of disease, the prognosis is usually very good, especially if there is no underlying illness compromising the immune system. For patients with compromised immune systems, including transplant patients, any delay of appropriate treatment may result in complications, prolonged hospitalisation and death. However after successful treatment and hospital discharge, many patients still experience fatigue, loss of energy and difficulty concentrating. These symptoms may persist for several months, but complete recovery usually occurs within one year.

===PONTIAC FEVER===
Pontiac fever is an acute, self-limiting, flu-like illness without symptoms of pneumonia. The first outbreak of Pontiac fever was reported in Pontiac, Michigan, in 1968.16

It is characterised by high fever, chills, myalgia and malaise but without the pneumonia or cough typical of Legionnaires’ disease. Some authors suggest that it is a hypersensitivity pneumonitis, caused either by infection with a free-living amoeba called ''Acanthamoeba'' filled with legionellae or as a result of a toxic reaction to the organism. The incubation period is short, ranging from 1 – 3 days, and the attack rate high, exceeding 90% in some cases. The fatality rate is low.

Pontiac fever symptoms usually resolve spontaneously within one week, only symptomatic treatment is needed and the chest radiograph is clear. There is no evidence of secondary spread of the infection in Pontiac fever. Diagnosis can only be made by seroconversion, which may be delayed for up to 6 weeks after onset of symptoms. Cases of PF have been linked to ''L pneumophila, L feelei and L anisa''. Complete recovery usually occurs in 2 – 5 days without medical attention.

==References==
<references />

== References Chapter 3 ==

# Dowling JN, McDaevitt DA, Pasculle AW. Isolation and preliminary characterization of erythromycin-resistant variants of Legionella micdadei and Legionella pneumophila. Agents Chemother. 1985, 27 (2): 272-274.
# MacFarlane JT, Miller AC, Smith WH, Morris AH, Rose DH. Comparative radiographic features of community acquired Legionnaires’ disease, pneumococcal pneumonia, Mycoplasma pneumonia and psittacosis. Thorax 1984, 39: 28-33.
# Boldur I, Beer S, Kazak R, Kahana H, Kannai Y. Predisposition of the asthmatic child to legionellosis? Isr. J. Med. Sci 1986, 22 (10): 733-736.
# Kurtz JB. Legionella pneumophila. Am. J. Occup. Hyg. 1988, 32 (1): 59-61.
# Shapiro M. Unusual epidemiologic and clinical manifestations of legionellosis: a review. Isr. J. Med. Sci. 1986, 22 (10): 724-727.
# Yu VL. Legionella pneumophila (Legionnaires’ disease). In: Mandell, Douglas and Bennet (eds). Principles and practice of infectious disease. 1990, Third Edition, Churchill Livingstone.
# Ratshikhopha ME, Klugman KP, Koornhof HJ. An evaluation of two indirect fluorescent antibody tests for the diagnosis of Legionnaires’ disease in South Africa. South African Med. J. 1990, 77: 392-395.
# Bartie C and Klugman KP. Exposures to Legionella pneumophila and Chlamydia pneumoniae in South African mine workers. Int. J. Occup. Environ. Health 1997, 3: 120-127.
# Maartens G, Lewis SJ, de Goveia C, Bartie C, Roditi D, Klugman KP. “Atypical” bacteria are a common cause of community acquired pneumonia in hospitalised adults. South African Med. J. 1994, 84: 678-682.
# Winn 1991
# Roig J, Aguilar X, Ruiz J, Domingo C, Mesalles E, Manterola J, Morera J. Comparative study of Legionella pneumophila and other nosocomial-acquired pneumonias. CHEST 1991, 99: 344-350.
# Stout JE, Yu VL. Legionellosis. New Engl. J. Med. 1997, 682-687.
# Ruf B, Schürman D, Horbach I, Fehrenbach FJ, Pohle HD. Prevalence and diagnosis of Legionella pneumonia: a 3-year prospective study with emphasis on application of urinary antigen detection. J. Inf. Dis. 1990, 162: 1341-1348.
# Harrison TG, Dournon E, Taylor AG. Evaluation of sensitivity of two serological tests for diagnosing pneumonia caused by Legionella pneumophila serogroup 1. J. Clin. Pathol. 1987, 40: 77-82.
# Pastoris MC, Ciarrochi S, Di Capula A, Temperanza AM. Comparison of phenol- and heat-killed antigens in the indirect immunofluorescence test for serodiagnosis of Legionella pneumophila serogroup 1 antigens. J. Clin. Microbiol. 1984, 20 (4): 780-783.
# Kaufmann AF, McDade JE, Patton CM, Bennett JV, Skalyi P, Feeley C, Anderson DC, Potter ME, Newhouse VF, Gregg MB, Brachman PS. Pontiac fever: isolation of the etiologic agent (Legionella pneumophila) and demonstration of its mode of transmission. Am. J. Epid. 1981, 114 (3): 337-347.

[[Category:Legionella Control]]
[[Category:Infection Prevention and Control]]
[[Category:Water Distributions Systems]]

File:FIGURE 3.3.jpg

2020-10-22T13:09:11Z

Tmojanaga:

Figure 3.3 Historical section of lung of Legionnaires disease patient

Legionella Control

2020-10-22T12:48:04Z

Tmojanaga: /* 3.4 DIAGNOSIS */

{{Stub}}
{{Anchor|Section1}}
==Section 1==
{{Expand}}

==Section 2==

==='''THE CHAIN OF INFECTION'''===
The mere presence of legionellae in a water distribution system does not necessarily imply a human health risk. For human infection to occur, certain conditions are necessary. These conditions are referred to as the “chain of infection” consisting of six links. All the links have to be present for disease to occur ([[#Legionella-Chain_of_Infection|Diagram: Chain of infection]] ). The first link, the pathogen, was discussed in [[#Section1|Section 1]].

{{Anchor|Legionella-Chain_of_Infection}}
[[File:Chain of infection.png|alt=Chain of infection|none|thumb|Chain of infection|450x450px]]

==='''SOURCES AND RESERVOIRS'''===
Legionellae are natural inhabitants of water, found a wide range of habitats. They are ubiquitous in streams, lakes and rivers. They also survive in dust, soil and mud. In fact, one of the species, ''Legionella longbeacheae'', is so often isolated from potting soil in Australia that soil has been suggested as the natural habitat of this particular species.<ref>Dennis PJ (1993). Potable water systems: insights into control. In: Barbaree JM, Breiman RF and Dufour AP (eds). Legionella: Current status and emerging perspectives. American Society for Microbiology, Washington DC. Pp 223-225.</ref>

{{Anchor|Natural sources of Legionella}}
[[File:Natural sources of Legionella.png|alt=Natural sources of Legionella|none|thumb|Chain of infection|450x450px]]

Legionellae from these natural environments can be transmitted to man-made water systems by various means. For example, from raw water, during water treatment, as part of post-treatment after-growths within water distribution systems, during building and construction activities and during plumbing repair.<ref>Colbourne JS and Dennis PJ (1985). Distribution and persistence of Legionella in water systems. ''Microbiol. Sc.'' '''2''': 40-43.</ref>

Once established, they can persist in the water supply for long periods of time and are difficult to eradicate. Therefore, their presence must be considered in all aspects of the design, operation and maintenance of buildings. For this to be effective, cooperation between engineers, occupational health practitioners and microbiologists is essential.

Figure 2.3 Man-made sources of Legionella

=====Water sources that provide optimal conditions for Legionella growth can be separated into those containing “non-potable” and those that contain “potable” water. '''Non-potable water distribution systems'''=====

Heat rejection devices like cooling towers, evaporative condensers and HVAC (heating, ventilation and air-conditioning) systems are often implicated as sources of legionellosis. They contain reservoirs filled with warm, recirculating water that makes them ideal for the growth, amplification and dissemination of micro organisms (including Legionella). In a typical water-cooled system air in induced through or blown over, packing material down which water, circulating from a pond under the packing, is allowed to fall by gravity, producing a large wetted surface that cools the falling water.

The constant fall of water through the tower, the large area of the basin, fill, pipes and heat exchanger, the warm temperature of the water, the high relative humidity and high organic content within these devices provide conditions that favour contamination by algae, protozoa, fungi and bacteria. The risk is increased further by the open nature of the systems, excessive aeration and the constant addition of fresh water to make up for water lost through evaporation.

In systems that are not regularly cleaned, sludge accumulates in the reservoir and slime adheres to water covered surfaces, resulting in the presence of large concentrations of micro-organisms, including legionellae, on these surfaces. In addition, water temperatures below 60°C, the age and configuration of the system, the pH of the water and the presence of certain metals may also increase the risk of contamination.

Water derived from municipal supplies but subsequently stored in cisterns, or conditioned prior to heating, is considered non-potable due to the deterioration in chemical and bacteriological quality during storage. Colonisation of such non-potable sources inside large buildings, such as hotels, factories or hospitals, may be a major cause of legionellosis.<ref>Muraca PW, Stout JE, Yu VL and Yee YC (1988). Mode of transmission of ''Legionella pneumophila''. A critical review. ''Am. J. Hyg. Assoc.'' '''49''': 584-590.</ref><ref>Yamamoto H, Sugiura M, Kusunoki S, Ezaki T, Ikedo M and Yabuuchi E (1992). Factors stimulating propagation of legionellae in cooling tower water. ''Appl. Environ. Microbiol.'' '''58''': 1394-1397</ref><ref name=":0">Freije MR (1996). Legionella control in healthcare facilities: A guide for minimising risk. HC Information Resources, Inc. United States of America. P 8</ref>

====='''Potable (domestic) water distribution systems'''=====
Legionellae are often present in potable water supplies, especially in the hot water sections of these systems. The organisms may enter potable water supplies from the main source, even from municipal water, and survive standard treatment protocols because most municipal water systems are not routinely screened for the presence of legionellae and the organisms are chlorine tolerant. Once inside the system, they find a suitable environment to multiply and are usually very difficult to eradicate.

Legionella levels can rise from very low to very high within short periods of time. The factors that give rise to these fluctuations are not well understood and often very hard to determine. These factors include the age and configuration of the pipes, the degree of scaling and sediment and the potential for biofilm formation within the system increase the risk of contamination. Water temperatures of 25 – 42°C, stagnation and the presence of certain free-living amoebae capable of supporting the intracellular growth of legionellae are often mentioned as amplifying factors in published reports. The biofilm and scale that form on surfaces in water distribution systems provide nutrients for legionellae and protect them from hot water and disinfectants. Some materials used in these systems, for example neoprene washers, are more readily colonised than others (See [[Legionella Control#Materials used in the construction of potable water lines and fixtures|Table]]). Building location may also play a role in the colonisation of potable water with legionellae.

Hot water tanks are often colonised with legionellae, especially at the bottom where a warm zone may develop and scale and sediment accumulate.<ref>MarrieTJ, Haldane D, Bezanson G and Peppard R (1992). Each water outlet is a unique ecological niche for ''Legionella pneumophila''. ''Epid. Infect.'' '''108''': 264-270</ref> Hot water piping, especially dead-legs, presents an additional risk as legionellae thrive in stagnant water.

====='''Soil'''=====
Outdoors, the soil may be contaminated through contact with Legionella-polluted water and become a source of airborne bacteria during earth moving operations, such as construction work.
{| class="wikitable"
|+{{Anchor|Materials used in the construction of potable water lines and fixtures}}'''Materials used in the construction of potable water lines and fixtures'''
|
'''Very good'''
|
Copper
|-
|
'''Good'''
|

Neoprene

Other synthetic materials
|-
|
'''Reasonable'''
|
Steel
|-
|
'''Not recommended'''
|
Rubber

Plastics
|}

===='''Amplification'''====
Legionellae are usually present in low numbers in natural sources. However, certain factors present in man-made reservoirs can promote Legionella growth and amplification. To improve our understanding of Legionella, its potential to cause disease and how to better control the organisms in water systems, we must understand these conditions. The most important factors amplifying Legionella numbers in man-made reservoirs are listed in the table [[Legionella Control#Amplifying factors for Legionella in man-made sources and reservoirs.|Amplifying factors for Legionella in man-made sources and reservoirs.]]
'''Remember'''
Temperature data is usually based on laboratory studies and is not from actual system (piping) studies, which makes it even less reliable to use for Legionella control. System temperature on its own should therefore not be relied upon for Legionella control, because the so-called “system temperature” rarely indicates one uniform temperature throughout the entire system. Therefore, maintaining the system temperature does not guarantee Legionella control. Also, in plumbing systems, especially larger and/or more complex piping systems, legionellae have been shown to survive at even higher temperatures due to biofilm, dead-legs, and other complexities. It has been suggested that potable water systems be operated at temperatures as high as possible but take into account the risk of scalding injuries and energy conservation requirements.
{| class="wikitable"
|+{{Anchor|Amplifying factors for Legionella in man-made sources and reservoirs}}'''Amplifying factors for Legionella in man-made sources and reservoirs'''
|
'''TEMPERATURE'''
|

Legionellae can survive over a wide range of temperatures (20 – 60°C) with an optimum growth temperature of 37 – 45°C as illustrated in the figure [[Legionella Control#Natural sources of Legionella|Natural sources of Legionella]] 
|-
|
'''pH'''
|

Legionellae can survive and multiply at a pH of 5.0 – 8.5 
|-
|
'''STAGNATION'''
|

The presence of stagnant water in distribution systems increases the risk of Legionella contamination 
|-
|
'''WATER TREATMENT'''
|

The type of water treatment used may affect the numbers of legionellae present in a distribution system 
|-
|
'''DISINFECTANTS'''
|

The type, concentration and persistence of residual disinfectants in the system may affect the numbers and types of legionellae present 
|-
|
'''CHEMICAL PARAMETERS'''
|

The presence of organic carbon and certain metals like zinc and copper may influence the risk of Legionella contamination 
|-
|
'''RELATIVE HUMIDITY'''
|

Legionellae survive best at 65% relative humidity (RH) and are least stable below 55% RH
|-
|
'''SLIME, ALGAE AND PROTOZOA'''
|

Amoebae, cyanobacteria and flavobacteria have been associated with the growth of legionellae in water distribution systems
 
|-
|
'''CORROSION PRODUCTS'''
|

Legionellae numbers are usually highest in sections where corrosion products are present
 
|-
|
'''CONSTRUCTION'''
|

Major construction has been associated with outbreaks of legionellosis.

It is believed that legionellae are released from the soil during excavations from where they can enter the cooling tower of the building, air intakes or water pipes, or may be inhaled directly. Another possibility is that, during construction, nutrients already present in dust and dirt may become more readily available for the organisms. In new buildings, plumbing should be flushed before use. Renovated buildings may contain stagnant water, that should be flushed out before returning the building to normal use.
 
|-
|
'''WATER PRESSURE'''
|

An increase in water pressure may send dirt into a system, providing a food source for the bacteria or may dislodge scale and sediment containing legionellae from pipes.
 
|-
|
'''BIOFILM, SCALE AND SEDIMENT'''
|

In hot water systems the concentrations of legionellae are usually highest within biofilms and at the openings of water outlets. Biofilms are widespread in nature, and on most man-made surfaces when submerged in water.

Legionellae are not only able to survive in biofilms, but can proliferate and attach to susceptible hosts like protozoa, depending on the type of material on which the biofilm is formed. For example:

· Legionellae have been found in biofilms forming on plastic surfaces in water piping systems. At a temperature of 40° they were shown to account for approximately 50% of the total biofilm flora;

· Legionellae are less likely to be present on copper surfaces because copper generally do not support biofouling. If present, the bacteria are usually found in small numbers;

· Metal plumbing components and associated corrosion products provide iron and other metals needed for Legionella, thereby supporting their survival and growth.

Sediment and scale assists in the growth of supporting organisms and free-living protozoa, increasing the risk of contamination by legionellae. For this reason, its presence often indicates a possibility of Legionella contamination.

Algal slime also provides a stable habitat for their survival and multiplication.
 
|}
'''Disinfectants'''
After disinfection, municipal water supplies usually travel several kilometers before it reaches the point of use. During this course, disinfectant residuals diminish and there is increasing exposure to potentially biofilm-contaminated piping. Although municipal water systems are required to be disinfected at their points of distribution to conform to existing standards for bacterial disinfection, these standards are based upon the absence of coliform bacteria and do not include any specific testing requirements for Legionella.

====='''Transmission'''=====
After growth and amplification of legionellae to potentially infectious levels, the next requirement in the chain of infection is to achieve transmission of the bacteria to a susceptible host. Modern technology like cooling towers used to recirculate water for air-conditioning and humidifying purposes and other ventilation systems can cause the formation and distribution of aerosols through which the organisms can spread. Transmission can also occur through direct installation, aspiration or ingestion (Table [[Legionella Control#Dissemination of Legionella bacteria|Dissemination of Legionella bacteria]]).
{| class="wikitable"
|+'''Dissemination of Legionella bacteria'''
|
'''AEROSOLISATION'''
|

The most widely accepted theory for Legionella transmission is that the organism is aerosolised from a water distribution system and is inhaled as droplets of respirable size. Aerosolisation may affect persons outside as well as inside a building.
 
|-
|
'''DIRECT INSTALLATION'''
|

Respiratory therapy devices have the potential to disseminate legionellae by delivering gases at high temperatures and volumes, and by generating concentrated aerosols, enabling them to bypass the normal defence mechanisms of the respiratory system.
 
|-
|
'''INGESTION'''
|

The fact that diarrhoea is one of the symptoms of Legionnaires’ disease suggests the gastro-intestinal tract as the source in some cases. After infection via this route, the bacteria may spread to the respiratory tract, thereby causing Legionnaires’ disease.
 
|-
|
'''ASPIRATION'''
|

Another well documented mode of transmission that effectively gets bacteria into the lungs is aspiration (a “choking process” that often occur during drinking, swallowing or dlearing the throat, and during respiratory therapy). Evidence suggests that it may be a more common mode for Legionella dissemination than previously believed although it has not been widely described in the literature.<blockquote>

'''REMEMBER!'''

Never presume that you cannot get Legionnaires’ disease

from drinking water containing Legionella.</blockquote>

|}
[[File:Influence of temperature on Legionella growth (Freije 1996).png|alt=Influence of temperature on Legionella growth|none|thumb|604x604px|Influence of temperature on Legionella growth <ref name=":0" />]]

====='''INFECTION AND HOST SUSCEPTIBILITY'''=====
Infections caused by Legionella species are collectively known as ''legionellosis'' and include Legionnaires’ disease and Pontiac fever. Subclinical (asymptomatic) infections have been reported. Legionellosis occurs worldwide, in people of all ages and race groups, with no evidence of person-to-person spread of infection. It is most common in summer and autumn months. The incidence of legionellosis varies from country to country and from region to region. Recently, an increase in the worldwide incidence of reported legionellosis cases has become evident. This may be explained by the availability of improved diagnostic and testing methods, increased awareness of the symptoms and improved surveillance. However legionellosis, especially sporadic cases, is still not always reported to public health authorities, making it difficult to estimate its true incidence.

The mode of transmission, inoculum size, particle size and host susceptibility influence the severity of infection. Approximately half of the currently known Legionella species are implicated in disease, but ''pneumophila'' is still considered to be the causative agent in about 80% of diagnosed cases. However, this picture might change as the number of available diagnostic tests increases – it is thus important to regard all legionellae a potentially pathogenic until proven otherwise.

==Section 3==
===LEGIONELLA INFECTIONS===
Infections caused by Legionella species are collectively known as legionellosis and include Legionnaires’ disease and Pontiac fever.1,2 Subclinical infections have been reported. Legionella infections occur worldwide in people of all ages and race groups with no evidence of person-to-person spread of infection.3,4

===LEGIONNAIRES’ DISEASE===
Legionnaires’ disease (LD) is a severe multisystem disease with pneumonia as the most predominant clinical finding. Clinical features are similar to those of other pneumonias, making it difficult to diagnose.5,6 Symptoms range from a mild cough and slight fever to a coma with widespread pulmonary infiltrates and multisystem failure. Survivors usually recover completely although lung fibrosis and neurological abnormalities may persist in some cases. LD has a low attack rate but the mortality rate is high.

Legionnaires’ disease outbreaks occur frequently all over the world. In the United States, Legionnaires’ disease is considered to be fairly common and legionellae are among the top three causes of sporadic, community-acquired pneumonia. However, many cases are still not reported, as Legionnaires’ disease is difficult to distinguish from other forms of pneumonia. Although only approximately 1,000 cases are reported to the Centers for Disease Control and Prevention (CDC), it is estimated that over 25,000 cases occur every year, causing more than 4,000 deaths.

Despite this, only one outbreak has been reported in South Africa to date. However, previous South African studies indicated antibody levels to L pneumophila in 65% of healthy blood donors, 36% of healthy mineworkers, 10% of healthy factory workers and 16% of hospitalised pneumonia patients.7,8 One study reported seroconverion to L.

pneumophila in 9% of patients hospitalised between 1987 and 1988 with symptoms of community-acquired pneumonia.9

 
[[File:Hillside figure 3.1.jpg|thumb|420x420px|Figure 3.1 Legionella pathology|alt=|center]]

Figure 3.1 Legionella pathology
===3.1 RISK FACTORS===
In order for LD to occur, the host must be susceptible to infection. Older people (above 50 years of age) are more commonly infected. Men are more likely to be infected (ratio 3:1) but the racial distribution is usually consistent with that of the population involved.10

Table 3.1 lists the most common risk factors.
{| class="wikitable"
|+
!
!Table 3.1 Risk factors for development of Legionnaires’ disease
|-
|'''Patient demographics'''
|Smoking
Chronic pulmonary disease

Immunosuppression

Renal transplantation

Renal dialysis

Alcohol ingestion

Age > 50 years

Male
|-
|'''Environmental risks'''
|Exposure to construction activities
Exposure to air conditioning systems

Exposure to home air conditioning

Travelling and accommodation in hotels

Potable water

Hospitalization
|}
Source: Winn 1984 10

[[File:FIGURE 3.2 HISTOLOGY.jpg|center|thumb|500x500px|Figure 3.2 Risk Factors]]

===3.2 SYMPTOMS===
Legionnaires’ disease presents with a broad spectrum of symptoms, ranging from mild cough and low fever to stupor, respiratory and multi organ failure. Pneumonia is the predominant clinical finding. Early symptoms are mainly non-specific and include fever, malaise, myalgias, anorexia and headache.6,11 The temperature often exceeds 40°C and the patient may present with a slightly productive cough. Chest pain, occasionally pleuritic, can be prominent and when coupled with hemoptysis, may mistakenly suggest pulmonary emboli. Gastrointestinal symptoms (watery stools) are prominent, especially diarrhoea, which occurs in 20-40% of cases. Relative bradycardia has been over-emphasised as a diagnostic finding but is often seen in elderly patients with advanced pneumonia. Hyponatremia (serum sodium concentration ≥ 130 mmol/l) occurs more frequently in Legionnaires’ disease than in other pneumonias.

Extrapulmonary Legionnaires’ disease is rare but the clinical manifestations are often dramatic. These infections can easily be overlooked since the degree of suspicion is generally low in these cases. Legionella has been implicated in cases of sinusitis, cellulitis, pancreatitis, peritonitis and pyelonephritis. The most common extrapulmonary site of infection is the heart. There have been numerous reports of myocarditis, pericarditis, postcardiotomy syndrome and prosthetic valve endocarditis. In most cases there is no pneumonia symptoms present. Wound infections have also been reported.11

===3.3 INCUBATION PERIOD===
LD has an incubation period (the time it takes for symptoms to appear after exposure) of 2 – 10 days. The onset of symptoms may be sudden or gradual.

===3.4 DIAGNOSIS===
There are no reliable distinguishing clinical features to distinguish LD from pneumonia caused by other etiologic agents. However, there are some clinical clues to assist in the diagnosis (Table 3.2).6
{| class="wikitable"
|+
!Table 3.2 Clinical clues to Legionnaires’ disease
!
|-
|'''CLUE'''
|'''EXAMPLE'''
|-
|'''PATIENT HISTORY AND PHYSICAL EXAMINATION'''
|
|-
|Presence of an epidemic or documented source of infection
|Family, friends or associates with similar infection and exposure
|-
|Prominent neurologic or gastrointestinal symptoms
|Pneumonia with confusion, nausea and vomiting
|-
|Non-response to aminoglycosides or beta-lactam antibiotics
|Worsening condition after 5 days on antibiotics
|-
|'''LABORATORY RESULTS OF PATIENT'''
|
|-
|Gram stain of sputum with many neutrophils but no bacteria
|Laboratory reports showing many neutrophils and few normal flora or no bacteria
|-
|Nodular peripheral infiltrates in chest radiographs
|Progression of unilateral opacities to bilateral nodular infiltrates over several days
|}

It is important to remember that a clinical diagnosis of LD always has to be confirmed with specialised laboratory tests. As not all laboratories are equipped to perform these tests routinely, the tests have to be specifically requested by the physician. Table 3.3 highlights some of the most commonly used laboratory tests.12

* '''Culture''' of Legionella organisms from clinical samples is still the gold standard for diagnosing LD. The technique is highly specific, provided appropirate samples are used, and about 1.5 to 3 times more sensitive than immunofluorescence. Transtracheal aspirates are best for culture, but sputum, bronchial aspirates, pleural exudates, lung biopsies as well as wound swabs and even autopsy material have been used successfully.11 Disadvantages of the culturing of legionellae for diagnostic purposes include possible inhibition by non-legionellae organisms present in the sample, slow growth and difficulties in distinguishing legionellae from other organisms on solid media. These factors must be taken into account when choosing a laboratory to test clinical samples for LD.

* '''Immunofluorescence''' is useful to detect antigens (direct immunofluorescence) or antibodies (indirect immunofluorescence) in clinical samples in cases where culture is not possible. Cross reactions with organisms other than Legionella in the direct immunofluorescence (DFA) test may cause false positive results, making accurate interpretation of the results essential.11,13 Indirect immunofluorescence (IFA) is the most specific of the currently available serological tests for LD. It is reproducible, sensitive and specific for the diagnosis of especially L. pneumophila infections, but may be affected by several factors, including the method of antigen preparation, method of antigen fixation during preparation of the reagent, the class of immunoglobulin it is designed to detect and strain differences.14,15

* '''The Legionella Urinary Antigen test5''' is a relatively inexpensive and rapid diagnostic test, but only detects infections caused by L pneumophila Serogroup 1. The test is commercially available as a radioimmunoassay (RIA) or an enzyme linked immunosorbent assay (ELISA). An advantage of this test is the relative ease with which urine samples can be obtained, especially in patients with a non-productive cough. Legionella antigens may persist in the urine of some patients for as long as one year.

* '''Serological tests''' are useful for epidemiologic studies but less valuable for physicians. Diagnosis by serology is based on a fourfold rise in antibody titre to ≥ 1:128 in paired samples (from the acute and convalescent stage of disease).13,15 However, the antibody response may not be detectable until 1-3 months after onset of illness. Single titres of ≥1:256 during convalescence in pneumonia patients is suggestive of legionellosis. Antibody screening should include both IgG and IgM because some patients may only have an IgM response.5

* Assays based on the '''polymerase chain reaction (PCR)''' have been used to detect legionellae in urine, broncho-alveolar lavage fluid and sputum. These tests are highly specific but not more sensitive than culture and are much more expensive to perform. Limitations of PCR tests include the possible presence of certain “PCR inhibitors” in sputum and blood samples. The major advantage of PCR is the rapidity of the test and the ability to detect species other than L pneumophila. PCR is not used routinely for the clinical diagnosis of LD.

{| class="wikitable"
|+
!Table 3.3 Sensitivity and specificity of laboratory tests for the diagnosis of Legionnaires’ disease
!
!
|-
|'''TEST'''
|'''SENSITIVITY (%)'''
|'''SPECIFICITY (%)'''
|-
|Culture from clinical samples
|80
|100
|-
|Direct immunofluorescence (DFA)
|33-70
|96-99
|-
|Indirect immunofluorescence (IFA)
|40-60
|96-99
|-
|Urinary antigen detection
|70
|100
|}
Source: Stout and Yu, 1997
 
===3.5 HISTOLOGY===
Pulmonary lesions usually consist of a mixture of neutrophils and macrophages, fibrin, proteinaceous material and red blood cells. Neutrophils and macrophages are often present in the centre of a lesion with mainly macrophages around the periphery.

Intracellular bacteria are present in both neutrophils and macrophages. Further away from the site of acute inflammation, bacteria are mainly seen inside the macrophages.10

Figure 3.3 Histological section of lung of Legionnaires disease patient

===3.6 CHEST RADIOGRAPHS===
Radiographic features in Legionnaires’ disease are mostly non-specific, and absent in Pontiac fever. Abnormalities occur from the third day post infection in most Legionnaires’ disease patients and usually do not correlate well with the severity of illness.11 However, the abnormalities correlate with the presence of the Legionella bacterium in sputum. The time required to show clearing of infiltrates on radiographs is variable and may range from 1-4 months. Some patients show diffuse alveolar damage. In the majority of patients with Legionnaires’ disease:

· Initial involvement is unilateral, predominantly in the lower lobe

· Bilateral involvement has been described

· Initial densities are poorly marginated, homogenous, rounded, occur either on the periphery or in the centre of the lung and may be mistaken for pulmonary infarction

· Pulmonary densities enlarge during later stages of disease

· Pulmonary densities have a typical ground glass appearance or dense consolidation

· Total opacification of the lung may occur

· Pleural effusions are present in 24-63% of cases caused by L pneumophila

· Pleural effusions are uncommon in L micdadei infections

· Hilar adenopathy seldom occurs

· Cavitation may occur in immunocompromised patients

· Cavitation rarely occurs in L micdadei infections

Figure 3.4 Chest radiograph of Legionnaires’ disease patient

===3.7 TREATMENT===
Treatment of LD requires the use of antibiotics. However, many antibiotics effective against other bacterial pneumonias are ineffective against Legionella as these drugs do not penetrate the pulmonary cells (alveolar macrophages) where infectious Legionella bacteria thrive.

Erythromycin was historically the drug of choice for the treatment of Legionnaires’ disease, but the newer macrolides (azithromycin) and quinolones (ciprofloxacin, levofloxacin, moxifloxacin, gemifloxacin, trovofloxacin have superior in vitro activity and greater intracellular and lung-tissue penetration.12 Other agents that have been shown to be effective include tetracycline, doxycycline, minocycline, trimethoprim- sulfamethoxazole.12 Rifampin is recommended as part of combination therapy with a macrolide or a quinolone for patients who are severely ill. The total duration of therapy is usually 10-14 days; however a 21-day course may be needed for immuno-compromised patients or those with extensive evidence of disease on chest radiographs.12

When LD patients are treated with appropriate antibiotics near the onset of disease, the prognosis is usually very good, especially if there is no underlying illness compromising the immune system. For patients with compromised immune systems, including transplant patients, any delay of appropriate treatment may result in complications, prolonged hospitalisation and death. However after successful treatment and hospital discharge, many patients still experience fatigue, loss of energy and difficulty concentrating. These symptoms may persist for several months, but complete recovery usually occurs within one year.

===PONTIAC FEVER===
Pontiac fever is an acute, self-limiting, flu-like illness without symptoms of pneumonia. The first outbreak of Pontiac fever was reported in Pontiac, Michigan, in 1968.16

It is characterised by high fever, chills, myalgia and malaise but without the pneumonia or cough typical of Legionnaires’ disease. Some authors suggest that it is a hypersensitivity pneumonitis, caused either by infection with a free-living amoeba called Acanthamoeba filled with legionellae or as a result of a toxic reaction to the organism. The incubation period is short, ranging from 1 – 3 days, and the attack rate high, exceeding 90% in some cases. The fatality rate is low.

Pontiac fever symptoms usually resolve spontaneously within one week, only symptomatic treatment is needed and the chest radiograph is clear. There is no evidence of secondary spread of the infection in Pontiac fever. Diagnosis can only be made by seroconversion, which may be delayed for up to 6 weeks after onset of symptoms. Cases of PF have been linked to L pneumophila, L feelei and L anisa. Complete recovery usually occurs in 2 – 5 days without medical attention

==References==
<references />
[[Category:Legionella Control]]
[[Category:Infection Prevention and Control]]
[[Category:Water Distributions Systems]]

Legionella Control

2020-10-22T12:29:50Z

Tmojanaga: /* SYMPTOMS */

{{Stub}}
{{Anchor|Section1}}
==Section 1==
{{Expand}}

==Section 2==

==='''THE CHAIN OF INFECTION'''===
The mere presence of legionellae in a water distribution system does not necessarily imply a human health risk. For human infection to occur, certain conditions are necessary. These conditions are referred to as the “chain of infection” consisting of six links. All the links have to be present for disease to occur ([[#Legionella-Chain_of_Infection|Diagram: Chain of infection]] ). The first link, the pathogen, was discussed in [[#Section1|Section 1]].

{{Anchor|Legionella-Chain_of_Infection}}
[[File:Chain of infection.png|alt=Chain of infection|none|thumb|Chain of infection|450x450px]]

==='''SOURCES AND RESERVOIRS'''===
Legionellae are natural inhabitants of water, found a wide range of habitats. They are ubiquitous in streams, lakes and rivers. They also survive in dust, soil and mud. In fact, one of the species, ''Legionella longbeacheae'', is so often isolated from potting soil in Australia that soil has been suggested as the natural habitat of this particular species.<ref>Dennis PJ (1993). Potable water systems: insights into control. In: Barbaree JM, Breiman RF and Dufour AP (eds). Legionella: Current status and emerging perspectives. American Society for Microbiology, Washington DC. Pp 223-225.</ref>

{{Anchor|Natural sources of Legionella}}
[[File:Natural sources of Legionella.png|alt=Natural sources of Legionella|none|thumb|Chain of infection|450x450px]]

Legionellae from these natural environments can be transmitted to man-made water systems by various means. For example, from raw water, during water treatment, as part of post-treatment after-growths within water distribution systems, during building and construction activities and during plumbing repair.<ref>Colbourne JS and Dennis PJ (1985). Distribution and persistence of Legionella in water systems. ''Microbiol. Sc.'' '''2''': 40-43.</ref>

Once established, they can persist in the water supply for long periods of time and are difficult to eradicate. Therefore, their presence must be considered in all aspects of the design, operation and maintenance of buildings. For this to be effective, cooperation between engineers, occupational health practitioners and microbiologists is essential.

Figure 2.3 Man-made sources of Legionella

=====Water sources that provide optimal conditions for Legionella growth can be separated into those containing “non-potable” and those that contain “potable” water. '''Non-potable water distribution systems'''=====

Heat rejection devices like cooling towers, evaporative condensers and HVAC (heating, ventilation and air-conditioning) systems are often implicated as sources of legionellosis. They contain reservoirs filled with warm, recirculating water that makes them ideal for the growth, amplification and dissemination of micro organisms (including Legionella). In a typical water-cooled system air in induced through or blown over, packing material down which water, circulating from a pond under the packing, is allowed to fall by gravity, producing a large wetted surface that cools the falling water.

The constant fall of water through the tower, the large area of the basin, fill, pipes and heat exchanger, the warm temperature of the water, the high relative humidity and high organic content within these devices provide conditions that favour contamination by algae, protozoa, fungi and bacteria. The risk is increased further by the open nature of the systems, excessive aeration and the constant addition of fresh water to make up for water lost through evaporation.

In systems that are not regularly cleaned, sludge accumulates in the reservoir and slime adheres to water covered surfaces, resulting in the presence of large concentrations of micro-organisms, including legionellae, on these surfaces. In addition, water temperatures below 60°C, the age and configuration of the system, the pH of the water and the presence of certain metals may also increase the risk of contamination.

Water derived from municipal supplies but subsequently stored in cisterns, or conditioned prior to heating, is considered non-potable due to the deterioration in chemical and bacteriological quality during storage. Colonisation of such non-potable sources inside large buildings, such as hotels, factories or hospitals, may be a major cause of legionellosis.<ref>Muraca PW, Stout JE, Yu VL and Yee YC (1988). Mode of transmission of ''Legionella pneumophila''. A critical review. ''Am. J. Hyg. Assoc.'' '''49''': 584-590.</ref><ref>Yamamoto H, Sugiura M, Kusunoki S, Ezaki T, Ikedo M and Yabuuchi E (1992). Factors stimulating propagation of legionellae in cooling tower water. ''Appl. Environ. Microbiol.'' '''58''': 1394-1397</ref><ref name=":0">Freije MR (1996). Legionella control in healthcare facilities: A guide for minimising risk. HC Information Resources, Inc. United States of America. P 8</ref>

====='''Potable (domestic) water distribution systems'''=====
Legionellae are often present in potable water supplies, especially in the hot water sections of these systems. The organisms may enter potable water supplies from the main source, even from municipal water, and survive standard treatment protocols because most municipal water systems are not routinely screened for the presence of legionellae and the organisms are chlorine tolerant. Once inside the system, they find a suitable environment to multiply and are usually very difficult to eradicate.

Legionella levels can rise from very low to very high within short periods of time. The factors that give rise to these fluctuations are not well understood and often very hard to determine. These factors include the age and configuration of the pipes, the degree of scaling and sediment and the potential for biofilm formation within the system increase the risk of contamination. Water temperatures of 25 – 42°C, stagnation and the presence of certain free-living amoebae capable of supporting the intracellular growth of legionellae are often mentioned as amplifying factors in published reports. The biofilm and scale that form on surfaces in water distribution systems provide nutrients for legionellae and protect them from hot water and disinfectants. Some materials used in these systems, for example neoprene washers, are more readily colonised than others (See [[Legionella Control#Materials used in the construction of potable water lines and fixtures|Table]]). Building location may also play a role in the colonisation of potable water with legionellae.

Hot water tanks are often colonised with legionellae, especially at the bottom where a warm zone may develop and scale and sediment accumulate.<ref>MarrieTJ, Haldane D, Bezanson G and Peppard R (1992). Each water outlet is a unique ecological niche for ''Legionella pneumophila''. ''Epid. Infect.'' '''108''': 264-270</ref> Hot water piping, especially dead-legs, presents an additional risk as legionellae thrive in stagnant water.

====='''Soil'''=====
Outdoors, the soil may be contaminated through contact with Legionella-polluted water and become a source of airborne bacteria during earth moving operations, such as construction work.
{| class="wikitable"
|+{{Anchor|Materials used in the construction of potable water lines and fixtures}}'''Materials used in the construction of potable water lines and fixtures'''
|
'''Very good'''
|
Copper
|-
|
'''Good'''
|

Neoprene

Other synthetic materials
|-
|
'''Reasonable'''
|
Steel
|-
|
'''Not recommended'''
|
Rubber

Plastics
|}

===='''Amplification'''====
Legionellae are usually present in low numbers in natural sources. However, certain factors present in man-made reservoirs can promote Legionella growth and amplification. To improve our understanding of Legionella, its potential to cause disease and how to better control the organisms in water systems, we must understand these conditions. The most important factors amplifying Legionella numbers in man-made reservoirs are listed in the table [[Legionella Control#Amplifying factors for Legionella in man-made sources and reservoirs.|Amplifying factors for Legionella in man-made sources and reservoirs.]]
'''Remember'''
Temperature data is usually based on laboratory studies and is not from actual system (piping) studies, which makes it even less reliable to use for Legionella control. System temperature on its own should therefore not be relied upon for Legionella control, because the so-called “system temperature” rarely indicates one uniform temperature throughout the entire system. Therefore, maintaining the system temperature does not guarantee Legionella control. Also, in plumbing systems, especially larger and/or more complex piping systems, legionellae have been shown to survive at even higher temperatures due to biofilm, dead-legs, and other complexities. It has been suggested that potable water systems be operated at temperatures as high as possible but take into account the risk of scalding injuries and energy conservation requirements.
{| class="wikitable"
|+{{Anchor|Amplifying factors for Legionella in man-made sources and reservoirs}}'''Amplifying factors for Legionella in man-made sources and reservoirs'''
|
'''TEMPERATURE'''
|

Legionellae can survive over a wide range of temperatures (20 – 60°C) with an optimum growth temperature of 37 – 45°C as illustrated in the figure [[Legionella Control#Natural sources of Legionella|Natural sources of Legionella]] 
|-
|
'''pH'''
|

Legionellae can survive and multiply at a pH of 5.0 – 8.5 
|-
|
'''STAGNATION'''
|

The presence of stagnant water in distribution systems increases the risk of Legionella contamination 
|-
|
'''WATER TREATMENT'''
|

The type of water treatment used may affect the numbers of legionellae present in a distribution system 
|-
|
'''DISINFECTANTS'''
|

The type, concentration and persistence of residual disinfectants in the system may affect the numbers and types of legionellae present 
|-
|
'''CHEMICAL PARAMETERS'''
|

The presence of organic carbon and certain metals like zinc and copper may influence the risk of Legionella contamination 
|-
|
'''RELATIVE HUMIDITY'''
|

Legionellae survive best at 65% relative humidity (RH) and are least stable below 55% RH
|-
|
'''SLIME, ALGAE AND PROTOZOA'''
|

Amoebae, cyanobacteria and flavobacteria have been associated with the growth of legionellae in water distribution systems
 
|-
|
'''CORROSION PRODUCTS'''
|

Legionellae numbers are usually highest in sections where corrosion products are present
 
|-
|
'''CONSTRUCTION'''
|

Major construction has been associated with outbreaks of legionellosis.

It is believed that legionellae are released from the soil during excavations from where they can enter the cooling tower of the building, air intakes or water pipes, or may be inhaled directly. Another possibility is that, during construction, nutrients already present in dust and dirt may become more readily available for the organisms. In new buildings, plumbing should be flushed before use. Renovated buildings may contain stagnant water, that should be flushed out before returning the building to normal use.
 
|-
|
'''WATER PRESSURE'''
|

An increase in water pressure may send dirt into a system, providing a food source for the bacteria or may dislodge scale and sediment containing legionellae from pipes.
 
|-
|
'''BIOFILM, SCALE AND SEDIMENT'''
|

In hot water systems the concentrations of legionellae are usually highest within biofilms and at the openings of water outlets. Biofilms are widespread in nature, and on most man-made surfaces when submerged in water.

Legionellae are not only able to survive in biofilms, but can proliferate and attach to susceptible hosts like protozoa, depending on the type of material on which the biofilm is formed. For example:

· Legionellae have been found in biofilms forming on plastic surfaces in water piping systems. At a temperature of 40° they were shown to account for approximately 50% of the total biofilm flora;

· Legionellae are less likely to be present on copper surfaces because copper generally do not support biofouling. If present, the bacteria are usually found in small numbers;

· Metal plumbing components and associated corrosion products provide iron and other metals needed for Legionella, thereby supporting their survival and growth.

Sediment and scale assists in the growth of supporting organisms and free-living protozoa, increasing the risk of contamination by legionellae. For this reason, its presence often indicates a possibility of Legionella contamination.

Algal slime also provides a stable habitat for their survival and multiplication.
 
|}
'''Disinfectants'''
After disinfection, municipal water supplies usually travel several kilometers before it reaches the point of use. During this course, disinfectant residuals diminish and there is increasing exposure to potentially biofilm-contaminated piping. Although municipal water systems are required to be disinfected at their points of distribution to conform to existing standards for bacterial disinfection, these standards are based upon the absence of coliform bacteria and do not include any specific testing requirements for Legionella.

====='''Transmission'''=====
After growth and amplification of legionellae to potentially infectious levels, the next requirement in the chain of infection is to achieve transmission of the bacteria to a susceptible host. Modern technology like cooling towers used to recirculate water for air-conditioning and humidifying purposes and other ventilation systems can cause the formation and distribution of aerosols through which the organisms can spread. Transmission can also occur through direct installation, aspiration or ingestion (Table [[Legionella Control#Dissemination of Legionella bacteria|Dissemination of Legionella bacteria]]).
{| class="wikitable"
|+'''Dissemination of Legionella bacteria'''
|
'''AEROSOLISATION'''
|

The most widely accepted theory for Legionella transmission is that the organism is aerosolised from a water distribution system and is inhaled as droplets of respirable size. Aerosolisation may affect persons outside as well as inside a building.
 
|-
|
'''DIRECT INSTALLATION'''
|

Respiratory therapy devices have the potential to disseminate legionellae by delivering gases at high temperatures and volumes, and by generating concentrated aerosols, enabling them to bypass the normal defence mechanisms of the respiratory system.
 
|-
|
'''INGESTION'''
|

The fact that diarrhoea is one of the symptoms of Legionnaires’ disease suggests the gastro-intestinal tract as the source in some cases. After infection via this route, the bacteria may spread to the respiratory tract, thereby causing Legionnaires’ disease.
 
|-
|
'''ASPIRATION'''
|

Another well documented mode of transmission that effectively gets bacteria into the lungs is aspiration (a “choking process” that often occur during drinking, swallowing or dlearing the throat, and during respiratory therapy). Evidence suggests that it may be a more common mode for Legionella dissemination than previously believed although it has not been widely described in the literature.<blockquote>

'''REMEMBER!'''

Never presume that you cannot get Legionnaires’ disease

from drinking water containing Legionella.</blockquote>

|}
[[File:Influence of temperature on Legionella growth (Freije 1996).png|alt=Influence of temperature on Legionella growth|none|thumb|604x604px|Influence of temperature on Legionella growth <ref name=":0" />]]

====='''INFECTION AND HOST SUSCEPTIBILITY'''=====
Infections caused by Legionella species are collectively known as ''legionellosis'' and include Legionnaires’ disease and Pontiac fever. Subclinical (asymptomatic) infections have been reported. Legionellosis occurs worldwide, in people of all ages and race groups, with no evidence of person-to-person spread of infection. It is most common in summer and autumn months. The incidence of legionellosis varies from country to country and from region to region. Recently, an increase in the worldwide incidence of reported legionellosis cases has become evident. This may be explained by the availability of improved diagnostic and testing methods, increased awareness of the symptoms and improved surveillance. However legionellosis, especially sporadic cases, is still not always reported to public health authorities, making it difficult to estimate its true incidence.

The mode of transmission, inoculum size, particle size and host susceptibility influence the severity of infection. Approximately half of the currently known Legionella species are implicated in disease, but ''pneumophila'' is still considered to be the causative agent in about 80% of diagnosed cases. However, this picture might change as the number of available diagnostic tests increases – it is thus important to regard all legionellae a potentially pathogenic until proven otherwise.

==Section 3==
===LEGIONELLA INFECTIONS===
Infections caused by Legionella species are collectively known as legionellosis and include Legionnaires’ disease and Pontiac fever.1,2 Subclinical infections have been reported. Legionella infections occur worldwide in people of all ages and race groups with no evidence of person-to-person spread of infection.3,4

===LEGIONNAIRES’ DISEASE===
Legionnaires’ disease (LD) is a severe multisystem disease with pneumonia as the most predominant clinical finding. Clinical features are similar to those of other pneumonias, making it difficult to diagnose.5,6 Symptoms range from a mild cough and slight fever to a coma with widespread pulmonary infiltrates and multisystem failure. Survivors usually recover completely although lung fibrosis and neurological abnormalities may persist in some cases. LD has a low attack rate but the mortality rate is high.

Legionnaires’ disease outbreaks occur frequently all over the world. In the United States, Legionnaires’ disease is considered to be fairly common and legionellae are among the top three causes of sporadic, community-acquired pneumonia. However, many cases are still not reported, as Legionnaires’ disease is difficult to distinguish from other forms of pneumonia. Although only approximately 1,000 cases are reported to the Centers for Disease Control and Prevention (CDC), it is estimated that over 25,000 cases occur every year, causing more than 4,000 deaths.

Despite this, only one outbreak has been reported in South Africa to date. However, previous South African studies indicated antibody levels to L pneumophila in 65% of healthy blood donors, 36% of healthy mineworkers, 10% of healthy factory workers and 16% of hospitalised pneumonia patients.7,8 One study reported seroconverion to L.

pneumophila in 9% of patients hospitalised between 1987 and 1988 with symptoms of community-acquired pneumonia.9

 
[[File:Hillside figure 3.1.jpg|thumb|420x420px|Figure 3.1 Legionella pathology|alt=|center]]

Figure 3.1 Legionella pathology
===3.1 RISK FACTORS===
In order for LD to occur, the host must be susceptible to infection. Older people (above 50 years of age) are more commonly infected. Men are more likely to be infected (ratio 3:1) but the racial distribution is usually consistent with that of the population involved.10

Table 3.1 lists the most common risk factors.
{| class="wikitable"
|+
!
!Table 3.1 Risk factors for development of Legionnaires’ disease
|-
|'''Patient demographics'''
|Smoking
Chronic pulmonary disease

Immunosuppression

Renal transplantation

Renal dialysis

Alcohol ingestion

Age > 50 years

Male
|-
|'''Environmental risks'''
|Exposure to construction activities
Exposure to air conditioning systems

Exposure to home air conditioning

Travelling and accommodation in hotels

Potable water

Hospitalization
|}
Source: Winn 1984 10

[[File:FIGURE 3.2 HISTOLOGY.jpg|center|thumb|500x500px|Figure 3.2 Risk Factors]]

===3.2 SYMPTOMS===
Legionnaires’ disease presents with a broad spectrum of symptoms, ranging from mild cough and low fever to stupor, respiratory and multi organ failure. Pneumonia is the predominant clinical finding. Early symptoms are mainly non-specific and include fever, malaise, myalgias, anorexia and headache.6,11 The temperature often exceeds 40°C and the patient may present with a slightly productive cough. Chest pain, occasionally pleuritic, can be prominent and when coupled with hemoptysis, may mistakenly suggest pulmonary emboli. Gastrointestinal symptoms (watery stools) are prominent, especially diarrhoea, which occurs in 20-40% of cases. Relative bradycardia has been over-emphasised as a diagnostic finding but is often seen in elderly patients with advanced pneumonia. Hyponatremia (serum sodium concentration ≥ 130 mmol/l) occurs more frequently in Legionnaires’ disease than in other pneumonias.

Extrapulmonary Legionnaires’ disease is rare but the clinical manifestations are often dramatic. These infections can easily be overlooked since the degree of suspicion is generally low in these cases. Legionella has been implicated in cases of sinusitis, cellulitis, pancreatitis, peritonitis and pyelonephritis. The most common extrapulmonary site of infection is the heart. There have been numerous reports of myocarditis, pericarditis, postcardiotomy syndrome and prosthetic valve endocarditis. In most cases there is no pneumonia symptoms present. Wound infections have also been reported.11

===3.3 INCUBATION PERIOD===
LD has an incubation period (the time it takes for symptoms to appear after exposure) of 2 – 10 days. The onset of symptoms may be sudden or gradual.

===3.4 DIAGNOSIS===
There are no reliable distinguishing clinical features to distinguish LD from pneumonia caused by other etiologic agents. However, there are some clinical clues to assist in the diagnosis (Table 3.2).6

Table 3.2 Clinical clues to Legionnaires’ disease

CLUE EXAMPLE

PATIENT HISTORY AND PHYSICAL EXAMINATION

Presence of an epidemic or documented source of

infection

Family, friends or associates with similar infection and exposure

Prominent neurologic or gastrointestinal symptoms

Pneumonia with confusion, nausea and vomiting

Non-response to aminoglycosides or beta-lactam

antibiotics

Worsening condition after 5 days on antibiotics

LABORATORY RESULTS OF PATIENT

Gram stain of sputum with many neutrophils but no

bacteria

Laboratory reports showing many neutrophils and few normal flora or no bacteria

Nodular peripheral infiltrates in chest radiographs Progression of unilateral opacities to bilateral nodular infiltrates over several days

It is important to remember that a clinical diagnosis of LD always has to be confirmed with specialised laboratory tests. As not all laboratories are equipped to perform these tests routinely, the tests have to be specifically requested by the physician. Table 3.3 highlights some of the most commonly used laboratory tests.12

· Culture of Legionella organisms from clinical samples is still the gold standard for diagnosing LD. The technique is highly specific, provided appropirate samples are used, and about 1.5 to 3 times more sensitive than immunofluorescence. Transtracheal aspirates are best for culture, but sputum, bronchial aspirates, pleural exudates, lung biopsies as well as wound swabs and even autopsy material have been used successfully.11 Disadvantages of the culturing of legionellae for diagnostic purposes include possible inhibition by non-legionellae organisms present in the sample, slow growth and difficulties in distinguishing legionellae from other organisms on solid media. These factors must be taken into account when choosing a laboratory to test clinical samples for LD.

· Immunofluorescence is useful to detect antigens (direct immunofluorescence) or antibodies (indirect immunofluorescence) in clinical samples in cases where culture is not possible. Cross reactions with organisms other than Legionella in the direct immunofluorescence (DFA) test may cause false positive results, making accurate

interpretation of the results essential.11,13 Indirect immunofluorescence (IFA) is the most specific of the currently available serological tests for LD. It is reproducible, sensitive and specific for the diagnosis of especially L. pneumophila infections, but may be affected by several factors, including the method of antigen preparation, method of antigen fixation during preparation of the reagent, the class of immunoglobulin it is designed to detect and strain differences.14,15

· The Legionella Urinary Antigen test5 is a relatively inexpensive and rapid diagnostic test, but only detects infections caused by L pneumophila Serogroup 1. The test is commercially available as a radioimmunoassay (RIA) or an enzyme linked immunosorbent assay (ELISA). An advantage of this test is the relative ease with which urine samples can be obtained, especially in patients with a non-productive cough. Legionella antigens may persist in the urine of some patients for as long as one year.

· Serological tests are useful for epidemiologic studies but less valuable for physicians. Diagnosis by serology is based on a fourfold rise in antibody titre to ≥ 1:128 in paired samples (from the acute and convalescent stage of disease).13,15 However, the antibody response may not be detectable until 1-3 months after onset of illness. Single titres of ≥1:256 during convalescence in pneumonia patients is suggestive of legionellosis. Antibody screening should include both IgG and IgM because some patients may only have an IgM response.5

· Assays based on the polymerase chain reaction (PCR) have been used to detect legionellae in urine, broncho-alveolar lavage fluid and sputum. These tests are highly specific but not more sensitive than culture and are much more expensive to perform. Limitations of PCR tests include the possible presence of certain “PCR inhibitors” in sputum and blood samples. The major advantage of PCR is the rapidity of the test and the ability to detect species other than L pneumophila. PCR is not used routinely for the clinical diagnosis of LD.

Table 3.3 Sensitivity and specificity of laboratory tests for the diagnosis of Legionnaires’ disease

TEST SENSITIVITY (%) SPECIFICITY (%)

Culture from clinical samples 80 100

Direct immunofluorescence (DFA) 33-70 96-99

Indirect immunofluorescence (IFA) 40-60 96-99

Urinary antigen detection 70 100

Source: Stout and Yu, 1997

===3.5 HISTOLOGY===
Pulmonary lesions usually consist of a mixture of neutrophils and macrophages, fibrin, proteinaceous material and red blood cells. Neutrophils and macrophages are often present in the centre of a lesion with mainly macrophages around the periphery.

Intracellular bacteria are present in both neutrophils and macrophages. Further away from the site of acute inflammation, bacteria are mainly seen inside the macrophages.10

Figure 3.3 Histological section of lung of Legionnaires disease patient

===3.6 CHEST RADIOGRAPHS===
Radiographic features in Legionnaires’ disease are mostly non-specific, and absent in Pontiac fever. Abnormalities occur from the third day post infection in most Legionnaires’ disease patients and usually do not correlate well with the severity of illness.11 However, the abnormalities correlate with the presence of the Legionella bacterium in sputum. The time required to show clearing of infiltrates on radiographs is variable and may range from 1-4 months. Some patients show diffuse alveolar damage. In the majority of patients with Legionnaires’ disease:

· Initial involvement is unilateral, predominantly in the lower lobe

· Bilateral involvement has been described

· Initial densities are poorly marginated, homogenous, rounded, occur either on the periphery or in the centre of the lung and may be mistaken for pulmonary infarction

· Pulmonary densities enlarge during later stages of disease

· Pulmonary densities have a typical ground glass appearance or dense consolidation

· Total opacification of the lung may occur

· Pleural effusions are present in 24-63% of cases caused by L pneumophila

· Pleural effusions are uncommon in L micdadei infections

· Hilar adenopathy seldom occurs

· Cavitation may occur in immunocompromised patients

· Cavitation rarely occurs in L micdadei infections

Figure 3.4 Chest radiograph of Legionnaires’ disease patient

===3.7 TREATMENT===
Treatment of LD requires the use of antibiotics. However, many antibiotics effective against other bacterial pneumonias are ineffective against Legionella as these drugs do not penetrate the pulmonary cells (alveolar macrophages) where infectious Legionella bacteria thrive.

Erythromycin was historically the drug of choice for the treatment of Legionnaires’ disease, but the newer macrolides (azithromycin) and quinolones (ciprofloxacin, levofloxacin, moxifloxacin, gemifloxacin, trovofloxacin have superior in vitro activity and greater intracellular and lung-tissue penetration.12 Other agents that have been shown to be effective include tetracycline, doxycycline, minocycline, trimethoprim- sulfamethoxazole.12 Rifampin is recommended as part of combination therapy with a macrolide or a quinolone for patients who are severely ill. The total duration of therapy is usually 10-14 days; however a 21-day course may be needed for immuno-compromised patients or those with extensive evidence of disease on chest radiographs.12

When LD patients are treated with appropriate antibiotics near the onset of disease, the prognosis is usually very good, especially if there is no underlying illness compromising the immune system. For patients with compromised immune systems, including transplant patients, any delay of appropriate treatment may result in complications, prolonged hospitalisation and death. However after successful treatment and hospital discharge, many patients still experience fatigue, loss of energy and difficulty concentrating. These symptoms may persist for several months, but complete recovery usually occurs within one year.

===PONTIAC FEVER===
Pontiac fever is an acute, self-limiting, flu-like illness without symptoms of pneumonia. The first outbreak of Pontiac fever was reported in Pontiac, Michigan, in 1968.16

It is characterised by high fever, chills, myalgia and malaise but without the pneumonia or cough typical of Legionnaires’ disease. Some authors suggest that it is a hypersensitivity pneumonitis, caused either by infection with a free-living amoeba called Acanthamoeba filled with legionellae or as a result of a toxic reaction to the organism. The incubation period is short, ranging from 1 – 3 days, and the attack rate high, exceeding 90% in some cases. The fatality rate is low.

Pontiac fever symptoms usually resolve spontaneously within one week, only symptomatic treatment is needed and the chest radiograph is clear. There is no evidence of secondary spread of the infection in Pontiac fever. Diagnosis can only be made by seroconversion, which may be delayed for up to 6 weeks after onset of symptoms. Cases of PF have been linked to L pneumophila, L feelei and L anisa. Complete recovery usually occurs in 2 – 5 days without medical attention

==References==
<references />
[[Category:Legionella Control]]
[[Category:Infection Prevention and Control]]
[[Category:Water Distributions Systems]]

Legionella Control

2020-10-22T12:22:14Z

Tmojanaga: /* RISK FACTORS */

{{Stub}}
{{Anchor|Section1}}
==Section 1==
{{Expand}}

==Section 2==

==='''THE CHAIN OF INFECTION'''===
The mere presence of legionellae in a water distribution system does not necessarily imply a human health risk. For human infection to occur, certain conditions are necessary. These conditions are referred to as the “chain of infection” consisting of six links. All the links have to be present for disease to occur ([[#Legionella-Chain_of_Infection|Diagram: Chain of infection]] ). The first link, the pathogen, was discussed in [[#Section1|Section 1]].

{{Anchor|Legionella-Chain_of_Infection}}
[[File:Chain of infection.png|alt=Chain of infection|none|thumb|Chain of infection|450x450px]]

==='''SOURCES AND RESERVOIRS'''===
Legionellae are natural inhabitants of water, found a wide range of habitats. They are ubiquitous in streams, lakes and rivers. They also survive in dust, soil and mud. In fact, one of the species, ''Legionella longbeacheae'', is so often isolated from potting soil in Australia that soil has been suggested as the natural habitat of this particular species.<ref>Dennis PJ (1993). Potable water systems: insights into control. In: Barbaree JM, Breiman RF and Dufour AP (eds). Legionella: Current status and emerging perspectives. American Society for Microbiology, Washington DC. Pp 223-225.</ref>

{{Anchor|Natural sources of Legionella}}
[[File:Natural sources of Legionella.png|alt=Natural sources of Legionella|none|thumb|Chain of infection|450x450px]]

Legionellae from these natural environments can be transmitted to man-made water systems by various means. For example, from raw water, during water treatment, as part of post-treatment after-growths within water distribution systems, during building and construction activities and during plumbing repair.<ref>Colbourne JS and Dennis PJ (1985). Distribution and persistence of Legionella in water systems. ''Microbiol. Sc.'' '''2''': 40-43.</ref>

Once established, they can persist in the water supply for long periods of time and are difficult to eradicate. Therefore, their presence must be considered in all aspects of the design, operation and maintenance of buildings. For this to be effective, cooperation between engineers, occupational health practitioners and microbiologists is essential.

Figure 2.3 Man-made sources of Legionella

=====Water sources that provide optimal conditions for Legionella growth can be separated into those containing “non-potable” and those that contain “potable” water. '''Non-potable water distribution systems'''=====

Heat rejection devices like cooling towers, evaporative condensers and HVAC (heating, ventilation and air-conditioning) systems are often implicated as sources of legionellosis. They contain reservoirs filled with warm, recirculating water that makes them ideal for the growth, amplification and dissemination of micro organisms (including Legionella). In a typical water-cooled system air in induced through or blown over, packing material down which water, circulating from a pond under the packing, is allowed to fall by gravity, producing a large wetted surface that cools the falling water.

The constant fall of water through the tower, the large area of the basin, fill, pipes and heat exchanger, the warm temperature of the water, the high relative humidity and high organic content within these devices provide conditions that favour contamination by algae, protozoa, fungi and bacteria. The risk is increased further by the open nature of the systems, excessive aeration and the constant addition of fresh water to make up for water lost through evaporation.

In systems that are not regularly cleaned, sludge accumulates in the reservoir and slime adheres to water covered surfaces, resulting in the presence of large concentrations of micro-organisms, including legionellae, on these surfaces. In addition, water temperatures below 60°C, the age and configuration of the system, the pH of the water and the presence of certain metals may also increase the risk of contamination.

Water derived from municipal supplies but subsequently stored in cisterns, or conditioned prior to heating, is considered non-potable due to the deterioration in chemical and bacteriological quality during storage. Colonisation of such non-potable sources inside large buildings, such as hotels, factories or hospitals, may be a major cause of legionellosis.<ref>Muraca PW, Stout JE, Yu VL and Yee YC (1988). Mode of transmission of ''Legionella pneumophila''. A critical review. ''Am. J. Hyg. Assoc.'' '''49''': 584-590.</ref><ref>Yamamoto H, Sugiura M, Kusunoki S, Ezaki T, Ikedo M and Yabuuchi E (1992). Factors stimulating propagation of legionellae in cooling tower water. ''Appl. Environ. Microbiol.'' '''58''': 1394-1397</ref><ref name=":0">Freije MR (1996). Legionella control in healthcare facilities: A guide for minimising risk. HC Information Resources, Inc. United States of America. P 8</ref>

====='''Potable (domestic) water distribution systems'''=====
Legionellae are often present in potable water supplies, especially in the hot water sections of these systems. The organisms may enter potable water supplies from the main source, even from municipal water, and survive standard treatment protocols because most municipal water systems are not routinely screened for the presence of legionellae and the organisms are chlorine tolerant. Once inside the system, they find a suitable environment to multiply and are usually very difficult to eradicate.

Legionella levels can rise from very low to very high within short periods of time. The factors that give rise to these fluctuations are not well understood and often very hard to determine. These factors include the age and configuration of the pipes, the degree of scaling and sediment and the potential for biofilm formation within the system increase the risk of contamination. Water temperatures of 25 – 42°C, stagnation and the presence of certain free-living amoebae capable of supporting the intracellular growth of legionellae are often mentioned as amplifying factors in published reports. The biofilm and scale that form on surfaces in water distribution systems provide nutrients for legionellae and protect them from hot water and disinfectants. Some materials used in these systems, for example neoprene washers, are more readily colonised than others (See [[Legionella Control#Materials used in the construction of potable water lines and fixtures|Table]]). Building location may also play a role in the colonisation of potable water with legionellae.

Hot water tanks are often colonised with legionellae, especially at the bottom where a warm zone may develop and scale and sediment accumulate.<ref>MarrieTJ, Haldane D, Bezanson G and Peppard R (1992). Each water outlet is a unique ecological niche for ''Legionella pneumophila''. ''Epid. Infect.'' '''108''': 264-270</ref> Hot water piping, especially dead-legs, presents an additional risk as legionellae thrive in stagnant water.

====='''Soil'''=====
Outdoors, the soil may be contaminated through contact with Legionella-polluted water and become a source of airborne bacteria during earth moving operations, such as construction work.
{| class="wikitable"
|+{{Anchor|Materials used in the construction of potable water lines and fixtures}}'''Materials used in the construction of potable water lines and fixtures'''
|
'''Very good'''
|
Copper
|-
|
'''Good'''
|

Neoprene

Other synthetic materials
|-
|
'''Reasonable'''
|
Steel
|-
|
'''Not recommended'''
|
Rubber

Plastics
|}

===='''Amplification'''====
Legionellae are usually present in low numbers in natural sources. However, certain factors present in man-made reservoirs can promote Legionella growth and amplification. To improve our understanding of Legionella, its potential to cause disease and how to better control the organisms in water systems, we must understand these conditions. The most important factors amplifying Legionella numbers in man-made reservoirs are listed in the table [[Legionella Control#Amplifying factors for Legionella in man-made sources and reservoirs.|Amplifying factors for Legionella in man-made sources and reservoirs.]]
'''Remember'''
Temperature data is usually based on laboratory studies and is not from actual system (piping) studies, which makes it even less reliable to use for Legionella control. System temperature on its own should therefore not be relied upon for Legionella control, because the so-called “system temperature” rarely indicates one uniform temperature throughout the entire system. Therefore, maintaining the system temperature does not guarantee Legionella control. Also, in plumbing systems, especially larger and/or more complex piping systems, legionellae have been shown to survive at even higher temperatures due to biofilm, dead-legs, and other complexities. It has been suggested that potable water systems be operated at temperatures as high as possible but take into account the risk of scalding injuries and energy conservation requirements.
{| class="wikitable"
|+{{Anchor|Amplifying factors for Legionella in man-made sources and reservoirs}}'''Amplifying factors for Legionella in man-made sources and reservoirs'''
|
'''TEMPERATURE'''
|

Legionellae can survive over a wide range of temperatures (20 – 60°C) with an optimum growth temperature of 37 – 45°C as illustrated in the figure [[Legionella Control#Natural sources of Legionella|Natural sources of Legionella]] 
|-
|
'''pH'''
|

Legionellae can survive and multiply at a pH of 5.0 – 8.5 
|-
|
'''STAGNATION'''
|

The presence of stagnant water in distribution systems increases the risk of Legionella contamination 
|-
|
'''WATER TREATMENT'''
|

The type of water treatment used may affect the numbers of legionellae present in a distribution system 
|-
|
'''DISINFECTANTS'''
|

The type, concentration and persistence of residual disinfectants in the system may affect the numbers and types of legionellae present 
|-
|
'''CHEMICAL PARAMETERS'''
|

The presence of organic carbon and certain metals like zinc and copper may influence the risk of Legionella contamination 
|-
|
'''RELATIVE HUMIDITY'''
|

Legionellae survive best at 65% relative humidity (RH) and are least stable below 55% RH
|-
|
'''SLIME, ALGAE AND PROTOZOA'''
|

Amoebae, cyanobacteria and flavobacteria have been associated with the growth of legionellae in water distribution systems
 
|-
|
'''CORROSION PRODUCTS'''
|

Legionellae numbers are usually highest in sections where corrosion products are present
 
|-
|
'''CONSTRUCTION'''
|

Major construction has been associated with outbreaks of legionellosis.

It is believed that legionellae are released from the soil during excavations from where they can enter the cooling tower of the building, air intakes or water pipes, or may be inhaled directly. Another possibility is that, during construction, nutrients already present in dust and dirt may become more readily available for the organisms. In new buildings, plumbing should be flushed before use. Renovated buildings may contain stagnant water, that should be flushed out before returning the building to normal use.
 
|-
|
'''WATER PRESSURE'''
|

An increase in water pressure may send dirt into a system, providing a food source for the bacteria or may dislodge scale and sediment containing legionellae from pipes.
 
|-
|
'''BIOFILM, SCALE AND SEDIMENT'''
|

In hot water systems the concentrations of legionellae are usually highest within biofilms and at the openings of water outlets. Biofilms are widespread in nature, and on most man-made surfaces when submerged in water.

Legionellae are not only able to survive in biofilms, but can proliferate and attach to susceptible hosts like protozoa, depending on the type of material on which the biofilm is formed. For example:

· Legionellae have been found in biofilms forming on plastic surfaces in water piping systems. At a temperature of 40° they were shown to account for approximately 50% of the total biofilm flora;

· Legionellae are less likely to be present on copper surfaces because copper generally do not support biofouling. If present, the bacteria are usually found in small numbers;

· Metal plumbing components and associated corrosion products provide iron and other metals needed for Legionella, thereby supporting their survival and growth.

Sediment and scale assists in the growth of supporting organisms and free-living protozoa, increasing the risk of contamination by legionellae. For this reason, its presence often indicates a possibility of Legionella contamination.

Algal slime also provides a stable habitat for their survival and multiplication.
 
|}
'''Disinfectants'''
After disinfection, municipal water supplies usually travel several kilometers before it reaches the point of use. During this course, disinfectant residuals diminish and there is increasing exposure to potentially biofilm-contaminated piping. Although municipal water systems are required to be disinfected at their points of distribution to conform to existing standards for bacterial disinfection, these standards are based upon the absence of coliform bacteria and do not include any specific testing requirements for Legionella.

====='''Transmission'''=====
After growth and amplification of legionellae to potentially infectious levels, the next requirement in the chain of infection is to achieve transmission of the bacteria to a susceptible host. Modern technology like cooling towers used to recirculate water for air-conditioning and humidifying purposes and other ventilation systems can cause the formation and distribution of aerosols through which the organisms can spread. Transmission can also occur through direct installation, aspiration or ingestion (Table [[Legionella Control#Dissemination of Legionella bacteria|Dissemination of Legionella bacteria]]).
{| class="wikitable"
|+'''Dissemination of Legionella bacteria'''
|
'''AEROSOLISATION'''
|

The most widely accepted theory for Legionella transmission is that the organism is aerosolised from a water distribution system and is inhaled as droplets of respirable size. Aerosolisation may affect persons outside as well as inside a building.
 
|-
|
'''DIRECT INSTALLATION'''
|

Respiratory therapy devices have the potential to disseminate legionellae by delivering gases at high temperatures and volumes, and by generating concentrated aerosols, enabling them to bypass the normal defence mechanisms of the respiratory system.
 
|-
|
'''INGESTION'''
|

The fact that diarrhoea is one of the symptoms of Legionnaires’ disease suggests the gastro-intestinal tract as the source in some cases. After infection via this route, the bacteria may spread to the respiratory tract, thereby causing Legionnaires’ disease.
 
|-
|
'''ASPIRATION'''
|

Another well documented mode of transmission that effectively gets bacteria into the lungs is aspiration (a “choking process” that often occur during drinking, swallowing or dlearing the throat, and during respiratory therapy). Evidence suggests that it may be a more common mode for Legionella dissemination than previously believed although it has not been widely described in the literature.<blockquote>

'''REMEMBER!'''

Never presume that you cannot get Legionnaires’ disease

from drinking water containing Legionella.</blockquote>

|}
[[File:Influence of temperature on Legionella growth (Freije 1996).png|alt=Influence of temperature on Legionella growth|none|thumb|604x604px|Influence of temperature on Legionella growth <ref name=":0" />]]

====='''INFECTION AND HOST SUSCEPTIBILITY'''=====
Infections caused by Legionella species are collectively known as ''legionellosis'' and include Legionnaires’ disease and Pontiac fever. Subclinical (asymptomatic) infections have been reported. Legionellosis occurs worldwide, in people of all ages and race groups, with no evidence of person-to-person spread of infection. It is most common in summer and autumn months. The incidence of legionellosis varies from country to country and from region to region. Recently, an increase in the worldwide incidence of reported legionellosis cases has become evident. This may be explained by the availability of improved diagnostic and testing methods, increased awareness of the symptoms and improved surveillance. However legionellosis, especially sporadic cases, is still not always reported to public health authorities, making it difficult to estimate its true incidence.

The mode of transmission, inoculum size, particle size and host susceptibility influence the severity of infection. Approximately half of the currently known Legionella species are implicated in disease, but ''pneumophila'' is still considered to be the causative agent in about 80% of diagnosed cases. However, this picture might change as the number of available diagnostic tests increases – it is thus important to regard all legionellae a potentially pathogenic until proven otherwise.

==Section 3==
===LEGIONELLA INFECTIONS===
Infections caused by Legionella species are collectively known as legionellosis and include Legionnaires’ disease and Pontiac fever.1,2 Subclinical infections have been reported. Legionella infections occur worldwide in people of all ages and race groups with no evidence of person-to-person spread of infection.3,4

===LEGIONNAIRES’ DISEASE===
Legionnaires’ disease (LD) is a severe multisystem disease with pneumonia as the most predominant clinical finding. Clinical features are similar to those of other pneumonias, making it difficult to diagnose.5,6 Symptoms range from a mild cough and slight fever to a coma with widespread pulmonary infiltrates and multisystem failure. Survivors usually recover completely although lung fibrosis and neurological abnormalities may persist in some cases. LD has a low attack rate but the mortality rate is high.

Legionnaires’ disease outbreaks occur frequently all over the world. In the United States, Legionnaires’ disease is considered to be fairly common and legionellae are among the top three causes of sporadic, community-acquired pneumonia. However, many cases are still not reported, as Legionnaires’ disease is difficult to distinguish from other forms of pneumonia. Although only approximately 1,000 cases are reported to the Centers for Disease Control and Prevention (CDC), it is estimated that over 25,000 cases occur every year, causing more than 4,000 deaths.

Despite this, only one outbreak has been reported in South Africa to date. However, previous South African studies indicated antibody levels to L pneumophila in 65% of healthy blood donors, 36% of healthy mineworkers, 10% of healthy factory workers and 16% of hospitalised pneumonia patients.7,8 One study reported seroconverion to L.

pneumophila in 9% of patients hospitalised between 1987 and 1988 with symptoms of community-acquired pneumonia.9

 
[[File:Hillside figure 3.1.jpg|thumb|420x420px|Figure 3.1 Legionella pathology|alt=|center]]

Figure 3.1 Legionella pathology
===RISK FACTORS===
In order for LD to occur, the host must be susceptible to infection. Older people (above 50 years of age) are more commonly infected. Men are more likely to be infected (ratio 3:1) but the racial distribution is usually consistent with that of the population involved.10

Table 3.1 lists the most common risk factors.
{| class="wikitable"
|+
!
!Table 3.1 Risk factors for development of Legionnaires’ disease
|-
|'''Patient demographics'''
|Smoking
Chronic pulmonary disease

Immunosuppression

Renal transplantation

Renal dialysis

Alcohol ingestion

Age > 50 years

Male
|-
|'''Environmental risks'''
|Exposure to construction activities
Exposure to air conditioning systems

Exposure to home air conditioning

Travelling and accommodation in hotels

Potable water

Hospitalization
|}
Source: Winn 1984 10

[[File:FIGURE 3.2 HISTOLOGY.jpg|center|thumb|500x500px|Figure 3.2 Risk Factors]]

===SYMPTOMS===
Legionnaires’ disease presents with a broad spectrum of symptoms, ranging from mild cough and low fever to stupor, respiratory and multi organ failure. Pneumonia is the predominant clinical finding. Early symptoms are mainly non-specific and include fever, malaise, myalgias, anorexia and headache.6,11 The temperature often exceeds 40°C and the patient may present with a slightly productive cough. Chest pain, occasionally pleuritic, can be prominent and when coupled with hemoptysis, may mistakenly suggest pulmonary emboli. Gastrointestinal symptoms (watery stools) are prominent, especially diarrhoea, which occurs in 20-40% of cases. Relative bradycardia has been over-

emphasised as a diagnostic finding but is often seen in elderly patients with advanced pneumonia. Hyponatremia (serum sodium concentration ≥ 130 mmol/l) occurs more frequently in Legionnaires’ disease than in other pneumonias.

Extrapulmonary Legionnaires’ disease is rare but the clinical manifestations are often dramatic. These infections can easily be overlooked since the degree of suspicion is generally low in these cases. Legionella has been implicated in cases of sinusitis, cellulitis, pancreatitis, peritonitis and pyelonephritis. The most common extrapulmonary site of infection is the heart. There have been numerous reports of myocarditis, pericarditis, postcardiotomy syndrome and prosthetic valve endocarditis. In most cases there is no pneumonia symptoms present. Wound infections have also been reported.11

===INCUBATION PERIOD===
LD has an incubation period (the time it takes for symptoms to appear after exposure) of 2 – 10 days. The onset of symptoms may be sudden or gradual.

===DIAGNOSIS===
There are no reliable distinguishing clinical features to distinguish LD from pneumonia caused by other etiologic agents. However, there are some clinical clues to assist in the diagnosis (Table 3.2).6

Table 3.2 Clinical clues to Legionnaires’ disease

CLUE EXAMPLE

PATIENT HISTORY AND PHYSICAL EXAMINATION

Presence of an epidemic or documented source of

infection

Family, friends or associates with similar infection and exposure

Prominent neurologic or gastrointestinal symptoms

Pneumonia with confusion, nausea and vomiting

Non-response to aminoglycosides or beta-lactam

antibiotics

Worsening condition after 5 days on antibiotics

LABORATORY RESULTS OF PATIENT

Gram stain of sputum with many neutrophils but no

bacteria

Laboratory reports showing many neutrophils and few normal flora or no bacteria

Nodular peripheral infiltrates in chest radiographs Progression of unilateral opacities to bilateral nodular infiltrates over several days

It is important to remember that a clinical diagnosis of LD always has to be confirmed with specialised laboratory tests. As not all laboratories are equipped to perform these tests routinely, the tests have to be specifically requested by the physician. Table 3.3 highlights some of the most commonly used laboratory tests.12

· Culture of Legionella organisms from clinical samples is still the gold standard for diagnosing LD. The technique is highly specific, provided appropirate samples are used, and about 1.5 to 3 times more sensitive than immunofluorescence. Transtracheal aspirates are best for culture, but sputum, bronchial aspirates, pleural exudates, lung biopsies as well as wound swabs and even autopsy material have been used successfully.11 Disadvantages of the culturing of legionellae for diagnostic purposes include possible inhibition by non-legionellae organisms present in the sample, slow growth and difficulties in distinguishing legionellae from other organisms on solid media. These factors must be taken into account when choosing a laboratory to test clinical samples for LD.

· Immunofluorescence is useful to detect antigens (direct immunofluorescence) or antibodies (indirect immunofluorescence) in clinical samples in cases where culture is not possible. Cross reactions with organisms other than Legionella in the direct immunofluorescence (DFA) test may cause false positive results, making accurate

interpretation of the results essential.11,13 Indirect immunofluorescence (IFA) is the most specific of the currently available serological tests for LD. It is reproducible, sensitive and specific for the diagnosis of especially L. pneumophila infections, but may be affected by several factors, including the method of antigen preparation, method of antigen fixation during preparation of the reagent, the class of immunoglobulin it is designed to detect and strain differences.14,15

· The Legionella Urinary Antigen test5 is a relatively inexpensive and rapid diagnostic test, but only detects infections caused by L pneumophila Serogroup 1. The test is commercially available as a radioimmunoassay (RIA) or an enzyme linked immunosorbent assay (ELISA). An advantage of this test is the relative ease with which urine samples can be obtained, especially in patients with a non-productive cough. Legionella antigens may persist in the urine of some patients for as long as one year.

· Serological tests are useful for epidemiologic studies but less valuable for physicians. Diagnosis by serology is based on a fourfold rise in antibody titre to ≥ 1:128 in paired samples (from the acute and convalescent stage of disease).13,15 However, the antibody response may not be detectable until 1-3 months after onset of illness. Single titres of ≥1:256 during convalescence in pneumonia patients is suggestive of legionellosis. Antibody screening should include both IgG and IgM because some patients may only have an IgM response.5

· Assays based on the polymerase chain reaction (PCR) have been used to detect legionellae in urine, broncho-alveolar lavage fluid and sputum. These tests are highly specific but not more sensitive than culture and are much more expensive to perform. Limitations of PCR tests include the possible presence of certain “PCR inhibitors” in sputum and blood samples. The major advantage of PCR is the rapidity of the test and the ability to detect species other than L pneumophila. PCR is not used routinely for the clinical diagnosis of LD.

Table 3.3 Sensitivity and specificity of laboratory tests for the diagnosis of Legionnaires’ disease

TEST SENSITIVITY (%) SPECIFICITY (%)

Culture from clinical samples 80 100

Direct immunofluorescence (DFA) 33-70 96-99

Indirect immunofluorescence (IFA) 40-60 96-99

Urinary antigen detection 70 100

Source: Stout and Yu, 1997

===3.5 HISTOLOGY===
Pulmonary lesions usually consist of a mixture of neutrophils and macrophages, fibrin, proteinaceous material and red blood cells. Neutrophils and macrophages are often present in the centre of a lesion with mainly macrophages around the periphery.

Intracellular bacteria are present in both neutrophils and macrophages. Further away from the site of acute inflammation, bacteria are mainly seen inside the macrophages.10

Figure 3.3 Histological section of lung of Legionnaires disease patient

===3.6 CHEST RADIOGRAPHS===
Radiographic features in Legionnaires’ disease are mostly non-specific, and absent in Pontiac fever. Abnormalities occur from the third day post infection in most Legionnaires’ disease patients and usually do not correlate well with the severity of illness.11 However, the abnormalities correlate with the presence of the Legionella bacterium in sputum. The time required to show clearing of infiltrates on radiographs is variable and may range from 1-4 months. Some patients show diffuse alveolar damage. In the majority of patients with Legionnaires’ disease:

· Initial involvement is unilateral, predominantly in the lower lobe

· Bilateral involvement has been described

· Initial densities are poorly marginated, homogenous, rounded, occur either on the periphery or in the centre of the lung and may be mistaken for pulmonary infarction

· Pulmonary densities enlarge during later stages of disease

· Pulmonary densities have a typical ground glass appearance or dense consolidation

· Total opacification of the lung may occur

· Pleural effusions are present in 24-63% of cases caused by L pneumophila

· Pleural effusions are uncommon in L micdadei infections

· Hilar adenopathy seldom occurs

· Cavitation may occur in immunocompromised patients

· Cavitation rarely occurs in L micdadei infections

Figure 3.4 Chest radiograph of Legionnaires’ disease patient

===3.7 TREATMENT===
Treatment of LD requires the use of antibiotics. However, many antibiotics effective against other bacterial pneumonias are ineffective against Legionella as these drugs do not penetrate the pulmonary cells (alveolar macrophages) where infectious Legionella bacteria thrive.

Erythromycin was historically the drug of choice for the treatment of Legionnaires’ disease, but the newer macrolides (azithromycin) and quinolones (ciprofloxacin, levofloxacin, moxifloxacin, gemifloxacin, trovofloxacin have superior in vitro activity and greater intracellular and lung-tissue penetration.12 Other agents that have been shown to be effective include tetracycline, doxycycline, minocycline, trimethoprim- sulfamethoxazole.12 Rifampin is recommended as part of combination therapy with a macrolide or a quinolone for patients who are severely ill. The total duration of therapy is usually 10-14 days; however a 21-day course may be needed for immuno-compromised patients or those with extensive evidence of disease on chest radiographs.12

When LD patients are treated with appropriate antibiotics near the onset of disease, the prognosis is usually very good, especially if there is no underlying illness compromising the immune system. For patients with compromised immune systems, including transplant patients, any delay of appropriate treatment may result in complications, prolonged hospitalisation and death. However after successful treatment and hospital discharge, many patients still experience fatigue, loss of energy and difficulty concentrating. These symptoms may persist for several months, but complete recovery usually occurs within one year.

===PONTIAC FEVER===
Pontiac fever is an acute, self-limiting, flu-like illness without symptoms of pneumonia. The first outbreak of Pontiac fever was reported in Pontiac, Michigan, in 1968.16

It is characterised by high fever, chills, myalgia and malaise but without the pneumonia or cough typical of Legionnaires’ disease. Some authors suggest that it is a hypersensitivity pneumonitis, caused either by infection with a free-living amoeba called Acanthamoeba filled with legionellae or as a result of a toxic reaction to the organism. The incubation period is short, ranging from 1 – 3 days, and the attack rate high, exceeding 90% in some cases. The fatality rate is low.

Pontiac fever symptoms usually resolve spontaneously within one week, only symptomatic treatment is needed and the chest radiograph is clear. There is no evidence of secondary spread of the infection in Pontiac fever. Diagnosis can only be made by seroconversion, which may be delayed for up to 6 weeks after onset of symptoms. Cases of PF have been linked to L pneumophila, L feelei and L anisa. Complete recovery usually occurs in 2 – 5 days without medical attention

==References==
<references />
[[Category:Legionella Control]]
[[Category:Infection Prevention and Control]]
[[Category:Water Distributions Systems]]

File:FIGURE 3.2 HISTOLOGY.jpg

2020-10-22T12:20:19Z

Tmojanaga:

Figure 3.2 Risk Factors

Legionella Control

2020-10-22T12:14:26Z

Tmojanaga: /* RISK FACTORS */ insertion of table

{{Stub}}
{{Anchor|Section1}}
==Section 1==
{{Expand}}

==Section 2==

==='''THE CHAIN OF INFECTION'''===
The mere presence of legionellae in a water distribution system does not necessarily imply a human health risk. For human infection to occur, certain conditions are necessary. These conditions are referred to as the “chain of infection” consisting of six links. All the links have to be present for disease to occur ([[#Legionella-Chain_of_Infection|Diagram: Chain of infection]] ). The first link, the pathogen, was discussed in [[#Section1|Section 1]].

{{Anchor|Legionella-Chain_of_Infection}}
[[File:Chain of infection.png|alt=Chain of infection|none|thumb|Chain of infection|450x450px]]

==='''SOURCES AND RESERVOIRS'''===
Legionellae are natural inhabitants of water, found a wide range of habitats. They are ubiquitous in streams, lakes and rivers. They also survive in dust, soil and mud. In fact, one of the species, ''Legionella longbeacheae'', is so often isolated from potting soil in Australia that soil has been suggested as the natural habitat of this particular species.<ref>Dennis PJ (1993). Potable water systems: insights into control. In: Barbaree JM, Breiman RF and Dufour AP (eds). Legionella: Current status and emerging perspectives. American Society for Microbiology, Washington DC. Pp 223-225.</ref>

{{Anchor|Natural sources of Legionella}}
[[File:Natural sources of Legionella.png|alt=Natural sources of Legionella|none|thumb|Chain of infection|450x450px]]

Legionellae from these natural environments can be transmitted to man-made water systems by various means. For example, from raw water, during water treatment, as part of post-treatment after-growths within water distribution systems, during building and construction activities and during plumbing repair.<ref>Colbourne JS and Dennis PJ (1985). Distribution and persistence of Legionella in water systems. ''Microbiol. Sc.'' '''2''': 40-43.</ref>

Once established, they can persist in the water supply for long periods of time and are difficult to eradicate. Therefore, their presence must be considered in all aspects of the design, operation and maintenance of buildings. For this to be effective, cooperation between engineers, occupational health practitioners and microbiologists is essential.

Figure 2.3 Man-made sources of Legionella

=====Water sources that provide optimal conditions for Legionella growth can be separated into those containing “non-potable” and those that contain “potable” water. '''Non-potable water distribution systems'''=====

Heat rejection devices like cooling towers, evaporative condensers and HVAC (heating, ventilation and air-conditioning) systems are often implicated as sources of legionellosis. They contain reservoirs filled with warm, recirculating water that makes them ideal for the growth, amplification and dissemination of micro organisms (including Legionella). In a typical water-cooled system air in induced through or blown over, packing material down which water, circulating from a pond under the packing, is allowed to fall by gravity, producing a large wetted surface that cools the falling water.

The constant fall of water through the tower, the large area of the basin, fill, pipes and heat exchanger, the warm temperature of the water, the high relative humidity and high organic content within these devices provide conditions that favour contamination by algae, protozoa, fungi and bacteria. The risk is increased further by the open nature of the systems, excessive aeration and the constant addition of fresh water to make up for water lost through evaporation.

In systems that are not regularly cleaned, sludge accumulates in the reservoir and slime adheres to water covered surfaces, resulting in the presence of large concentrations of micro-organisms, including legionellae, on these surfaces. In addition, water temperatures below 60°C, the age and configuration of the system, the pH of the water and the presence of certain metals may also increase the risk of contamination.

Water derived from municipal supplies but subsequently stored in cisterns, or conditioned prior to heating, is considered non-potable due to the deterioration in chemical and bacteriological quality during storage. Colonisation of such non-potable sources inside large buildings, such as hotels, factories or hospitals, may be a major cause of legionellosis.<ref>Muraca PW, Stout JE, Yu VL and Yee YC (1988). Mode of transmission of ''Legionella pneumophila''. A critical review. ''Am. J. Hyg. Assoc.'' '''49''': 584-590.</ref><ref>Yamamoto H, Sugiura M, Kusunoki S, Ezaki T, Ikedo M and Yabuuchi E (1992). Factors stimulating propagation of legionellae in cooling tower water. ''Appl. Environ. Microbiol.'' '''58''': 1394-1397</ref><ref name=":0">Freije MR (1996). Legionella control in healthcare facilities: A guide for minimising risk. HC Information Resources, Inc. United States of America. P 8</ref>

====='''Potable (domestic) water distribution systems'''=====
Legionellae are often present in potable water supplies, especially in the hot water sections of these systems. The organisms may enter potable water supplies from the main source, even from municipal water, and survive standard treatment protocols because most municipal water systems are not routinely screened for the presence of legionellae and the organisms are chlorine tolerant. Once inside the system, they find a suitable environment to multiply and are usually very difficult to eradicate.

Legionella levels can rise from very low to very high within short periods of time. The factors that give rise to these fluctuations are not well understood and often very hard to determine. These factors include the age and configuration of the pipes, the degree of scaling and sediment and the potential for biofilm formation within the system increase the risk of contamination. Water temperatures of 25 – 42°C, stagnation and the presence of certain free-living amoebae capable of supporting the intracellular growth of legionellae are often mentioned as amplifying factors in published reports. The biofilm and scale that form on surfaces in water distribution systems provide nutrients for legionellae and protect them from hot water and disinfectants. Some materials used in these systems, for example neoprene washers, are more readily colonised than others (See [[Legionella Control#Materials used in the construction of potable water lines and fixtures|Table]]). Building location may also play a role in the colonisation of potable water with legionellae.

Hot water tanks are often colonised with legionellae, especially at the bottom where a warm zone may develop and scale and sediment accumulate.<ref>MarrieTJ, Haldane D, Bezanson G and Peppard R (1992). Each water outlet is a unique ecological niche for ''Legionella pneumophila''. ''Epid. Infect.'' '''108''': 264-270</ref> Hot water piping, especially dead-legs, presents an additional risk as legionellae thrive in stagnant water.

====='''Soil'''=====
Outdoors, the soil may be contaminated through contact with Legionella-polluted water and become a source of airborne bacteria during earth moving operations, such as construction work.
{| class="wikitable"
|+{{Anchor|Materials used in the construction of potable water lines and fixtures}}'''Materials used in the construction of potable water lines and fixtures'''
|
'''Very good'''
|
Copper
|-
|
'''Good'''
|

Neoprene

Other synthetic materials
|-
|
'''Reasonable'''
|
Steel
|-
|
'''Not recommended'''
|
Rubber

Plastics
|}

===='''Amplification'''====
Legionellae are usually present in low numbers in natural sources. However, certain factors present in man-made reservoirs can promote Legionella growth and amplification. To improve our understanding of Legionella, its potential to cause disease and how to better control the organisms in water systems, we must understand these conditions. The most important factors amplifying Legionella numbers in man-made reservoirs are listed in the table [[Legionella Control#Amplifying factors for Legionella in man-made sources and reservoirs.|Amplifying factors for Legionella in man-made sources and reservoirs.]]
'''Remember'''
Temperature data is usually based on laboratory studies and is not from actual system (piping) studies, which makes it even less reliable to use for Legionella control. System temperature on its own should therefore not be relied upon for Legionella control, because the so-called “system temperature” rarely indicates one uniform temperature throughout the entire system. Therefore, maintaining the system temperature does not guarantee Legionella control. Also, in plumbing systems, especially larger and/or more complex piping systems, legionellae have been shown to survive at even higher temperatures due to biofilm, dead-legs, and other complexities. It has been suggested that potable water systems be operated at temperatures as high as possible but take into account the risk of scalding injuries and energy conservation requirements.
{| class="wikitable"
|+{{Anchor|Amplifying factors for Legionella in man-made sources and reservoirs}}'''Amplifying factors for Legionella in man-made sources and reservoirs'''
|
'''TEMPERATURE'''
|

Legionellae can survive over a wide range of temperatures (20 – 60°C) with an optimum growth temperature of 37 – 45°C as illustrated in the figure [[Legionella Control#Natural sources of Legionella|Natural sources of Legionella]] 
|-
|
'''pH'''
|

Legionellae can survive and multiply at a pH of 5.0 – 8.5 
|-
|
'''STAGNATION'''
|

The presence of stagnant water in distribution systems increases the risk of Legionella contamination 
|-
|
'''WATER TREATMENT'''
|

The type of water treatment used may affect the numbers of legionellae present in a distribution system 
|-
|
'''DISINFECTANTS'''
|

The type, concentration and persistence of residual disinfectants in the system may affect the numbers and types of legionellae present 
|-
|
'''CHEMICAL PARAMETERS'''
|

The presence of organic carbon and certain metals like zinc and copper may influence the risk of Legionella contamination 
|-
|
'''RELATIVE HUMIDITY'''
|

Legionellae survive best at 65% relative humidity (RH) and are least stable below 55% RH
|-
|
'''SLIME, ALGAE AND PROTOZOA'''
|

Amoebae, cyanobacteria and flavobacteria have been associated with the growth of legionellae in water distribution systems
 
|-
|
'''CORROSION PRODUCTS'''
|

Legionellae numbers are usually highest in sections where corrosion products are present
 
|-
|
'''CONSTRUCTION'''
|

Major construction has been associated with outbreaks of legionellosis.

It is believed that legionellae are released from the soil during excavations from where they can enter the cooling tower of the building, air intakes or water pipes, or may be inhaled directly. Another possibility is that, during construction, nutrients already present in dust and dirt may become more readily available for the organisms. In new buildings, plumbing should be flushed before use. Renovated buildings may contain stagnant water, that should be flushed out before returning the building to normal use.
 
|-
|
'''WATER PRESSURE'''
|

An increase in water pressure may send dirt into a system, providing a food source for the bacteria or may dislodge scale and sediment containing legionellae from pipes.
 
|-
|
'''BIOFILM, SCALE AND SEDIMENT'''
|

In hot water systems the concentrations of legionellae are usually highest within biofilms and at the openings of water outlets. Biofilms are widespread in nature, and on most man-made surfaces when submerged in water.

Legionellae are not only able to survive in biofilms, but can proliferate and attach to susceptible hosts like protozoa, depending on the type of material on which the biofilm is formed. For example:

· Legionellae have been found in biofilms forming on plastic surfaces in water piping systems. At a temperature of 40° they were shown to account for approximately 50% of the total biofilm flora;

· Legionellae are less likely to be present on copper surfaces because copper generally do not support biofouling. If present, the bacteria are usually found in small numbers;

· Metal plumbing components and associated corrosion products provide iron and other metals needed for Legionella, thereby supporting their survival and growth.

Sediment and scale assists in the growth of supporting organisms and free-living protozoa, increasing the risk of contamination by legionellae. For this reason, its presence often indicates a possibility of Legionella contamination.

Algal slime also provides a stable habitat for their survival and multiplication.
 
|}
'''Disinfectants'''
After disinfection, municipal water supplies usually travel several kilometers before it reaches the point of use. During this course, disinfectant residuals diminish and there is increasing exposure to potentially biofilm-contaminated piping. Although municipal water systems are required to be disinfected at their points of distribution to conform to existing standards for bacterial disinfection, these standards are based upon the absence of coliform bacteria and do not include any specific testing requirements for Legionella.

====='''Transmission'''=====
After growth and amplification of legionellae to potentially infectious levels, the next requirement in the chain of infection is to achieve transmission of the bacteria to a susceptible host. Modern technology like cooling towers used to recirculate water for air-conditioning and humidifying purposes and other ventilation systems can cause the formation and distribution of aerosols through which the organisms can spread. Transmission can also occur through direct installation, aspiration or ingestion (Table [[Legionella Control#Dissemination of Legionella bacteria|Dissemination of Legionella bacteria]]).
{| class="wikitable"
|+'''Dissemination of Legionella bacteria'''
|
'''AEROSOLISATION'''
|

The most widely accepted theory for Legionella transmission is that the organism is aerosolised from a water distribution system and is inhaled as droplets of respirable size. Aerosolisation may affect persons outside as well as inside a building.
 
|-
|
'''DIRECT INSTALLATION'''
|

Respiratory therapy devices have the potential to disseminate legionellae by delivering gases at high temperatures and volumes, and by generating concentrated aerosols, enabling them to bypass the normal defence mechanisms of the respiratory system.
 
|-
|
'''INGESTION'''
|

The fact that diarrhoea is one of the symptoms of Legionnaires’ disease suggests the gastro-intestinal tract as the source in some cases. After infection via this route, the bacteria may spread to the respiratory tract, thereby causing Legionnaires’ disease.
 
|-
|
'''ASPIRATION'''
|

Another well documented mode of transmission that effectively gets bacteria into the lungs is aspiration (a “choking process” that often occur during drinking, swallowing or dlearing the throat, and during respiratory therapy). Evidence suggests that it may be a more common mode for Legionella dissemination than previously believed although it has not been widely described in the literature.<blockquote>

'''REMEMBER!'''

Never presume that you cannot get Legionnaires’ disease

from drinking water containing Legionella.</blockquote>

|}
[[File:Influence of temperature on Legionella growth (Freije 1996).png|alt=Influence of temperature on Legionella growth|none|thumb|604x604px|Influence of temperature on Legionella growth <ref name=":0" />]]

====='''INFECTION AND HOST SUSCEPTIBILITY'''=====
Infections caused by Legionella species are collectively known as ''legionellosis'' and include Legionnaires’ disease and Pontiac fever. Subclinical (asymptomatic) infections have been reported. Legionellosis occurs worldwide, in people of all ages and race groups, with no evidence of person-to-person spread of infection. It is most common in summer and autumn months. The incidence of legionellosis varies from country to country and from region to region. Recently, an increase in the worldwide incidence of reported legionellosis cases has become evident. This may be explained by the availability of improved diagnostic and testing methods, increased awareness of the symptoms and improved surveillance. However legionellosis, especially sporadic cases, is still not always reported to public health authorities, making it difficult to estimate its true incidence.

The mode of transmission, inoculum size, particle size and host susceptibility influence the severity of infection. Approximately half of the currently known Legionella species are implicated in disease, but ''pneumophila'' is still considered to be the causative agent in about 80% of diagnosed cases. However, this picture might change as the number of available diagnostic tests increases – it is thus important to regard all legionellae a potentially pathogenic until proven otherwise.

==Section 3==
===LEGIONELLA INFECTIONS===
Infections caused by Legionella species are collectively known as legionellosis and include Legionnaires’ disease and Pontiac fever.1,2 Subclinical infections have been reported. Legionella infections occur worldwide in people of all ages and race groups with no evidence of person-to-person spread of infection.3,4

===LEGIONNAIRES’ DISEASE===
Legionnaires’ disease (LD) is a severe multisystem disease with pneumonia as the most predominant clinical finding. Clinical features are similar to those of other pneumonias, making it difficult to diagnose.5,6 Symptoms range from a mild cough and slight fever to a coma with widespread pulmonary infiltrates and multisystem failure. Survivors usually recover completely although lung fibrosis and neurological abnormalities may persist in some cases. LD has a low attack rate but the mortality rate is high.

Legionnaires’ disease outbreaks occur frequently all over the world. In the United States, Legionnaires’ disease is considered to be fairly common and legionellae are among the top three causes of sporadic, community-acquired pneumonia. However, many cases are still not reported, as Legionnaires’ disease is difficult to distinguish from other forms of pneumonia. Although only approximately 1,000 cases are reported to the Centers for Disease Control and Prevention (CDC), it is estimated that over 25,000 cases occur every year, causing more than 4,000 deaths.

Despite this, only one outbreak has been reported in South Africa to date. However, previous South African studies indicated antibody levels to L pneumophila in 65% of healthy blood donors, 36% of healthy mineworkers, 10% of healthy factory workers and 16% of hospitalised pneumonia patients.7,8 One study reported seroconverion to L.

pneumophila in 9% of patients hospitalised between 1987 and 1988 with symptoms of community-acquired pneumonia.9

 
[[File:Hillside figure 3.1.jpg|thumb|420x420px|Figure 3.1 Legionella pathology|alt=|center]]

Figure 3.1 Legionella pathology
===RISK FACTORS===
In order for LD to occur, the host must be susceptible to infection. Older people (above 50 years of age) are more commonly infected. Men are more likely to be infected (ratio 3:1) but the racial distribution is usually consistent with that of the population involved.10

Table 3.1 lists the most common risk factors.
{| class="wikitable"
|+
!
!Table 3.1 Risk factors for development of Legionnaires’ disease
|-
|'''Patient demographics'''
|Smoking
Chronic pulmonary disease

Immunosuppression

Renal transplantation

Renal dialysis

Alcohol ingestion

Age > 50 years

Male
|-
|'''Environmental risks'''
|Exposure to construction activities
Exposure to air conditioning systems

Exposure to home air conditioning

Travelling and accommodation in hotels

Potable water

Hospitalization
|}
Source: Winn 1984 10

===SYMPTOMS===
Legionnaires’ disease presents with a broad spectrum of symptoms, ranging from mild cough and low fever to stupor, respiratory and multi organ failure. Pneumonia is the predominant clinical finding. Early symptoms are mainly non-specific and include fever, malaise, myalgias, anorexia and headache.6,11 The temperature often exceeds 40°C and the patient may present with a slightly productive cough. Chest pain, occasionally pleuritic, can be prominent and when coupled with hemoptysis, may mistakenly suggest pulmonary emboli. Gastrointestinal symptoms (watery stools) are prominent, especially diarrhoea, which occurs in 20-40% of cases. Relative bradycardia has been over-

emphasised as a diagnostic finding but is often seen in elderly patients with advanced pneumonia. Hyponatremia (serum sodium concentration ≥ 130 mmol/l) occurs more frequently in Legionnaires’ disease than in other pneumonias.

Extrapulmonary Legionnaires’ disease is rare but the clinical manifestations are often dramatic. These infections can easily be overlooked since the degree of suspicion is generally low in these cases. Legionella has been implicated in cases of sinusitis, cellulitis, pancreatitis, peritonitis and pyelonephritis. The most common extrapulmonary site of infection is the heart. There have been numerous reports of myocarditis, pericarditis, postcardiotomy syndrome and prosthetic valve endocarditis. In most cases there is no pneumonia symptoms present. Wound infections have also been reported.11

===INCUBATION PERIOD===
LD has an incubation period (the time it takes for symptoms to appear after exposure) of 2 – 10 days. The onset of symptoms may be sudden or gradual.

===DIAGNOSIS===
There are no reliable distinguishing clinical features to distinguish LD from pneumonia caused by other etiologic agents. However, there are some clinical clues to assist in the diagnosis (Table 3.2).6

Table 3.2 Clinical clues to Legionnaires’ disease

CLUE EXAMPLE

PATIENT HISTORY AND PHYSICAL EXAMINATION

Presence of an epidemic or documented source of

infection

Family, friends or associates with similar infection and exposure

Prominent neurologic or gastrointestinal symptoms

Pneumonia with confusion, nausea and vomiting

Non-response to aminoglycosides or beta-lactam

antibiotics

Worsening condition after 5 days on antibiotics

LABORATORY RESULTS OF PATIENT

Gram stain of sputum with many neutrophils but no

bacteria

Laboratory reports showing many neutrophils and few normal flora or no bacteria

Nodular peripheral infiltrates in chest radiographs Progression of unilateral opacities to bilateral nodular infiltrates over several days

It is important to remember that a clinical diagnosis of LD always has to be confirmed with specialised laboratory tests. As not all laboratories are equipped to perform these tests routinely, the tests have to be specifically requested by the physician. Table 3.3 highlights some of the most commonly used laboratory tests.12

· Culture of Legionella organisms from clinical samples is still the gold standard for diagnosing LD. The technique is highly specific, provided appropirate samples are used, and about 1.5 to 3 times more sensitive than immunofluorescence. Transtracheal aspirates are best for culture, but sputum, bronchial aspirates, pleural exudates, lung biopsies as well as wound swabs and even autopsy material have been used successfully.11 Disadvantages of the culturing of legionellae for diagnostic purposes include possible inhibition by non-legionellae organisms present in the sample, slow growth and difficulties in distinguishing legionellae from other organisms on solid media. These factors must be taken into account when choosing a laboratory to test clinical samples for LD.

· Immunofluorescence is useful to detect antigens (direct immunofluorescence) or antibodies (indirect immunofluorescence) in clinical samples in cases where culture is not possible. Cross reactions with organisms other than Legionella in the direct immunofluorescence (DFA) test may cause false positive results, making accurate

interpretation of the results essential.11,13 Indirect immunofluorescence (IFA) is the most specific of the currently available serological tests for LD. It is reproducible, sensitive and specific for the diagnosis of especially L. pneumophila infections, but may be affected by several factors, including the method of antigen preparation, method of antigen fixation during preparation of the reagent, the class of immunoglobulin it is designed to detect and strain differences.14,15

· The Legionella Urinary Antigen test5 is a relatively inexpensive and rapid diagnostic test, but only detects infections caused by L pneumophila Serogroup 1. The test is commercially available as a radioimmunoassay (RIA) or an enzyme linked immunosorbent assay (ELISA). An advantage of this test is the relative ease with which urine samples can be obtained, especially in patients with a non-productive cough. Legionella antigens may persist in the urine of some patients for as long as one year.

· Serological tests are useful for epidemiologic studies but less valuable for physicians. Diagnosis by serology is based on a fourfold rise in antibody titre to ≥ 1:128 in paired samples (from the acute and convalescent stage of disease).13,15 However, the antibody response may not be detectable until 1-3 months after onset of illness. Single titres of ≥1:256 during convalescence in pneumonia patients is suggestive of legionellosis. Antibody screening should include both IgG and IgM because some patients may only have an IgM response.5

· Assays based on the polymerase chain reaction (PCR) have been used to detect legionellae in urine, broncho-alveolar lavage fluid and sputum. These tests are highly specific but not more sensitive than culture and are much more expensive to perform. Limitations of PCR tests include the possible presence of certain “PCR inhibitors” in sputum and blood samples. The major advantage of PCR is the rapidity of the test and the ability to detect species other than L pneumophila. PCR is not used routinely for the clinical diagnosis of LD.

Table 3.3 Sensitivity and specificity of laboratory tests for the diagnosis of Legionnaires’ disease

TEST SENSITIVITY (%) SPECIFICITY (%)

Culture from clinical samples 80 100

Direct immunofluorescence (DFA) 33-70 96-99

Indirect immunofluorescence (IFA) 40-60 96-99

Urinary antigen detection 70 100

Source: Stout and Yu, 1997

===3.5 HISTOLOGY===
Pulmonary lesions usually consist of a mixture of neutrophils and macrophages, fibrin, proteinaceous material and red blood cells. Neutrophils and macrophages are often present in the centre of a lesion with mainly macrophages around the periphery.

Intracellular bacteria are present in both neutrophils and macrophages. Further away from the site of acute inflammation, bacteria are mainly seen inside the macrophages.10

Figure 3.3 Histological section of lung of Legionnaires disease patient

===3.6 CHEST RADIOGRAPHS===
Radiographic features in Legionnaires’ disease are mostly non-specific, and absent in Pontiac fever. Abnormalities occur from the third day post infection in most Legionnaires’ disease patients and usually do not correlate well with the severity of illness.11 However, the abnormalities correlate with the presence of the Legionella bacterium in sputum. The time required to show clearing of infiltrates on radiographs is variable and may range from 1-4 months. Some patients show diffuse alveolar damage. In the majority of patients with Legionnaires’ disease:

· Initial involvement is unilateral, predominantly in the lower lobe

· Bilateral involvement has been described

· Initial densities are poorly marginated, homogenous, rounded, occur either on the periphery or in the centre of the lung and may be mistaken for pulmonary infarction

· Pulmonary densities enlarge during later stages of disease

· Pulmonary densities have a typical ground glass appearance or dense consolidation

· Total opacification of the lung may occur

· Pleural effusions are present in 24-63% of cases caused by L pneumophila

· Pleural effusions are uncommon in L micdadei infections

· Hilar adenopathy seldom occurs

· Cavitation may occur in immunocompromised patients

· Cavitation rarely occurs in L micdadei infections

Figure 3.4 Chest radiograph of Legionnaires’ disease patient

===3.7 TREATMENT===
Treatment of LD requires the use of antibiotics. However, many antibiotics effective against other bacterial pneumonias are ineffective against Legionella as these drugs do not penetrate the pulmonary cells (alveolar macrophages) where infectious Legionella bacteria thrive.

Erythromycin was historically the drug of choice for the treatment of Legionnaires’ disease, but the newer macrolides (azithromycin) and quinolones (ciprofloxacin, levofloxacin, moxifloxacin, gemifloxacin, trovofloxacin have superior in vitro activity and greater intracellular and lung-tissue penetration.12 Other agents that have been shown to be effective include tetracycline, doxycycline, minocycline, trimethoprim- sulfamethoxazole.12 Rifampin is recommended as part of combination therapy with a macrolide or a quinolone for patients who are severely ill. The total duration of therapy is usually 10-14 days; however a 21-day course may be needed for immuno-compromised patients or those with extensive evidence of disease on chest radiographs.12

When LD patients are treated with appropriate antibiotics near the onset of disease, the prognosis is usually very good, especially if there is no underlying illness compromising the immune system. For patients with compromised immune systems, including transplant patients, any delay of appropriate treatment may result in complications, prolonged hospitalisation and death. However after successful treatment and hospital discharge, many patients still experience fatigue, loss of energy and difficulty concentrating. These symptoms may persist for several months, but complete recovery usually occurs within one year.

===PONTIAC FEVER===
Pontiac fever is an acute, self-limiting, flu-like illness without symptoms of pneumonia. The first outbreak of Pontiac fever was reported in Pontiac, Michigan, in 1968.16

It is characterised by high fever, chills, myalgia and malaise but without the pneumonia or cough typical of Legionnaires’ disease. Some authors suggest that it is a hypersensitivity pneumonitis, caused either by infection with a free-living amoeba called Acanthamoeba filled with legionellae or as a result of a toxic reaction to the organism. The incubation period is short, ranging from 1 – 3 days, and the attack rate high, exceeding 90% in some cases. The fatality rate is low.

Pontiac fever symptoms usually resolve spontaneously within one week, only symptomatic treatment is needed and the chest radiograph is clear. There is no evidence of secondary spread of the infection in Pontiac fever. Diagnosis can only be made by seroconversion, which may be delayed for up to 6 weeks after onset of symptoms. Cases of PF have been linked to L pneumophila, L feelei and L anisa. Complete recovery usually occurs in 2 – 5 days without medical attention

==References==
<references />
[[Category:Legionella Control]]
[[Category:Infection Prevention and Control]]
[[Category:Water Distributions Systems]]

Legionella Control

2020-10-22T11:52:43Z

Tmojanaga: /* RISK FACTORS */

{{Stub}}
{{Anchor|Section1}}
==Section 1==
{{Expand}}

==Section 2==

==='''THE CHAIN OF INFECTION'''===
The mere presence of legionellae in a water distribution system does not necessarily imply a human health risk. For human infection to occur, certain conditions are necessary. These conditions are referred to as the “chain of infection” consisting of six links. All the links have to be present for disease to occur ([[#Legionella-Chain_of_Infection|Diagram: Chain of infection]] ). The first link, the pathogen, was discussed in [[#Section1|Section 1]].

{{Anchor|Legionella-Chain_of_Infection}}
[[File:Chain of infection.png|alt=Chain of infection|none|thumb|Chain of infection|450x450px]]

==='''SOURCES AND RESERVOIRS'''===
Legionellae are natural inhabitants of water, found a wide range of habitats. They are ubiquitous in streams, lakes and rivers. They also survive in dust, soil and mud. In fact, one of the species, ''Legionella longbeacheae'', is so often isolated from potting soil in Australia that soil has been suggested as the natural habitat of this particular species.<ref>Dennis PJ (1993). Potable water systems: insights into control. In: Barbaree JM, Breiman RF and Dufour AP (eds). Legionella: Current status and emerging perspectives. American Society for Microbiology, Washington DC. Pp 223-225.</ref>

{{Anchor|Natural sources of Legionella}}
[[File:Natural sources of Legionella.png|alt=Natural sources of Legionella|none|thumb|Chain of infection|450x450px]]

Legionellae from these natural environments can be transmitted to man-made water systems by various means. For example, from raw water, during water treatment, as part of post-treatment after-growths within water distribution systems, during building and construction activities and during plumbing repair.<ref>Colbourne JS and Dennis PJ (1985). Distribution and persistence of Legionella in water systems. ''Microbiol. Sc.'' '''2''': 40-43.</ref>

Once established, they can persist in the water supply for long periods of time and are difficult to eradicate. Therefore, their presence must be considered in all aspects of the design, operation and maintenance of buildings. For this to be effective, cooperation between engineers, occupational health practitioners and microbiologists is essential.

Figure 2.3 Man-made sources of Legionella

=====Water sources that provide optimal conditions for Legionella growth can be separated into those containing “non-potable” and those that contain “potable” water. '''Non-potable water distribution systems'''=====

Heat rejection devices like cooling towers, evaporative condensers and HVAC (heating, ventilation and air-conditioning) systems are often implicated as sources of legionellosis. They contain reservoirs filled with warm, recirculating water that makes them ideal for the growth, amplification and dissemination of micro organisms (including Legionella). In a typical water-cooled system air in induced through or blown over, packing material down which water, circulating from a pond under the packing, is allowed to fall by gravity, producing a large wetted surface that cools the falling water.

The constant fall of water through the tower, the large area of the basin, fill, pipes and heat exchanger, the warm temperature of the water, the high relative humidity and high organic content within these devices provide conditions that favour contamination by algae, protozoa, fungi and bacteria. The risk is increased further by the open nature of the systems, excessive aeration and the constant addition of fresh water to make up for water lost through evaporation.

In systems that are not regularly cleaned, sludge accumulates in the reservoir and slime adheres to water covered surfaces, resulting in the presence of large concentrations of micro-organisms, including legionellae, on these surfaces. In addition, water temperatures below 60°C, the age and configuration of the system, the pH of the water and the presence of certain metals may also increase the risk of contamination.

Water derived from municipal supplies but subsequently stored in cisterns, or conditioned prior to heating, is considered non-potable due to the deterioration in chemical and bacteriological quality during storage. Colonisation of such non-potable sources inside large buildings, such as hotels, factories or hospitals, may be a major cause of legionellosis.<ref>Muraca PW, Stout JE, Yu VL and Yee YC (1988). Mode of transmission of ''Legionella pneumophila''. A critical review. ''Am. J. Hyg. Assoc.'' '''49''': 584-590.</ref><ref>Yamamoto H, Sugiura M, Kusunoki S, Ezaki T, Ikedo M and Yabuuchi E (1992). Factors stimulating propagation of legionellae in cooling tower water. ''Appl. Environ. Microbiol.'' '''58''': 1394-1397</ref><ref name=":0">Freije MR (1996). Legionella control in healthcare facilities: A guide for minimising risk. HC Information Resources, Inc. United States of America. P 8</ref>

====='''Potable (domestic) water distribution systems'''=====
Legionellae are often present in potable water supplies, especially in the hot water sections of these systems. The organisms may enter potable water supplies from the main source, even from municipal water, and survive standard treatment protocols because most municipal water systems are not routinely screened for the presence of legionellae and the organisms are chlorine tolerant. Once inside the system, they find a suitable environment to multiply and are usually very difficult to eradicate.

Legionella levels can rise from very low to very high within short periods of time. The factors that give rise to these fluctuations are not well understood and often very hard to determine. These factors include the age and configuration of the pipes, the degree of scaling and sediment and the potential for biofilm formation within the system increase the risk of contamination. Water temperatures of 25 – 42°C, stagnation and the presence of certain free-living amoebae capable of supporting the intracellular growth of legionellae are often mentioned as amplifying factors in published reports. The biofilm and scale that form on surfaces in water distribution systems provide nutrients for legionellae and protect them from hot water and disinfectants. Some materials used in these systems, for example neoprene washers, are more readily colonised than others (See [[Legionella Control#Materials used in the construction of potable water lines and fixtures|Table]]). Building location may also play a role in the colonisation of potable water with legionellae.

Hot water tanks are often colonised with legionellae, especially at the bottom where a warm zone may develop and scale and sediment accumulate.<ref>MarrieTJ, Haldane D, Bezanson G and Peppard R (1992). Each water outlet is a unique ecological niche for ''Legionella pneumophila''. ''Epid. Infect.'' '''108''': 264-270</ref> Hot water piping, especially dead-legs, presents an additional risk as legionellae thrive in stagnant water.

====='''Soil'''=====
Outdoors, the soil may be contaminated through contact with Legionella-polluted water and become a source of airborne bacteria during earth moving operations, such as construction work.
{| class="wikitable"
|+{{Anchor|Materials used in the construction of potable water lines and fixtures}}'''Materials used in the construction of potable water lines and fixtures'''
|
'''Very good'''
|
Copper
|-
|
'''Good'''
|

Neoprene

Other synthetic materials
|-
|
'''Reasonable'''
|
Steel
|-
|
'''Not recommended'''
|
Rubber

Plastics
|}

===='''Amplification'''====
Legionellae are usually present in low numbers in natural sources. However, certain factors present in man-made reservoirs can promote Legionella growth and amplification. To improve our understanding of Legionella, its potential to cause disease and how to better control the organisms in water systems, we must understand these conditions. The most important factors amplifying Legionella numbers in man-made reservoirs are listed in the table [[Legionella Control#Amplifying factors for Legionella in man-made sources and reservoirs.|Amplifying factors for Legionella in man-made sources and reservoirs.]]
'''Remember'''
Temperature data is usually based on laboratory studies and is not from actual system (piping) studies, which makes it even less reliable to use for Legionella control. System temperature on its own should therefore not be relied upon for Legionella control, because the so-called “system temperature” rarely indicates one uniform temperature throughout the entire system. Therefore, maintaining the system temperature does not guarantee Legionella control. Also, in plumbing systems, especially larger and/or more complex piping systems, legionellae have been shown to survive at even higher temperatures due to biofilm, dead-legs, and other complexities. It has been suggested that potable water systems be operated at temperatures as high as possible but take into account the risk of scalding injuries and energy conservation requirements.
{| class="wikitable"
|+{{Anchor|Amplifying factors for Legionella in man-made sources and reservoirs}}'''Amplifying factors for Legionella in man-made sources and reservoirs'''
|
'''TEMPERATURE'''
|

Legionellae can survive over a wide range of temperatures (20 – 60°C) with an optimum growth temperature of 37 – 45°C as illustrated in the figure [[Legionella Control#Natural sources of Legionella|Natural sources of Legionella]] 
|-
|
'''pH'''
|

Legionellae can survive and multiply at a pH of 5.0 – 8.5 
|-
|
'''STAGNATION'''
|

The presence of stagnant water in distribution systems increases the risk of Legionella contamination 
|-
|
'''WATER TREATMENT'''
|

The type of water treatment used may affect the numbers of legionellae present in a distribution system 
|-
|
'''DISINFECTANTS'''
|

The type, concentration and persistence of residual disinfectants in the system may affect the numbers and types of legionellae present 
|-
|
'''CHEMICAL PARAMETERS'''
|

The presence of organic carbon and certain metals like zinc and copper may influence the risk of Legionella contamination 
|-
|
'''RELATIVE HUMIDITY'''
|

Legionellae survive best at 65% relative humidity (RH) and are least stable below 55% RH
|-
|
'''SLIME, ALGAE AND PROTOZOA'''
|

Amoebae, cyanobacteria and flavobacteria have been associated with the growth of legionellae in water distribution systems
 
|-
|
'''CORROSION PRODUCTS'''
|

Legionellae numbers are usually highest in sections where corrosion products are present
 
|-
|
'''CONSTRUCTION'''
|

Major construction has been associated with outbreaks of legionellosis.

It is believed that legionellae are released from the soil during excavations from where they can enter the cooling tower of the building, air intakes or water pipes, or may be inhaled directly. Another possibility is that, during construction, nutrients already present in dust and dirt may become more readily available for the organisms. In new buildings, plumbing should be flushed before use. Renovated buildings may contain stagnant water, that should be flushed out before returning the building to normal use.
 
|-
|
'''WATER PRESSURE'''
|

An increase in water pressure may send dirt into a system, providing a food source for the bacteria or may dislodge scale and sediment containing legionellae from pipes.
 
|-
|
'''BIOFILM, SCALE AND SEDIMENT'''
|

In hot water systems the concentrations of legionellae are usually highest within biofilms and at the openings of water outlets. Biofilms are widespread in nature, and on most man-made surfaces when submerged in water.

Legionellae are not only able to survive in biofilms, but can proliferate and attach to susceptible hosts like protozoa, depending on the type of material on which the biofilm is formed. For example:

· Legionellae have been found in biofilms forming on plastic surfaces in water piping systems. At a temperature of 40° they were shown to account for approximately 50% of the total biofilm flora;

· Legionellae are less likely to be present on copper surfaces because copper generally do not support biofouling. If present, the bacteria are usually found in small numbers;

· Metal plumbing components and associated corrosion products provide iron and other metals needed for Legionella, thereby supporting their survival and growth.

Sediment and scale assists in the growth of supporting organisms and free-living protozoa, increasing the risk of contamination by legionellae. For this reason, its presence often indicates a possibility of Legionella contamination.

Algal slime also provides a stable habitat for their survival and multiplication.
 
|}
'''Disinfectants'''
After disinfection, municipal water supplies usually travel several kilometers before it reaches the point of use. During this course, disinfectant residuals diminish and there is increasing exposure to potentially biofilm-contaminated piping. Although municipal water systems are required to be disinfected at their points of distribution to conform to existing standards for bacterial disinfection, these standards are based upon the absence of coliform bacteria and do not include any specific testing requirements for Legionella.

====='''Transmission'''=====
After growth and amplification of legionellae to potentially infectious levels, the next requirement in the chain of infection is to achieve transmission of the bacteria to a susceptible host. Modern technology like cooling towers used to recirculate water for air-conditioning and humidifying purposes and other ventilation systems can cause the formation and distribution of aerosols through which the organisms can spread. Transmission can also occur through direct installation, aspiration or ingestion (Table [[Legionella Control#Dissemination of Legionella bacteria|Dissemination of Legionella bacteria]]).
{| class="wikitable"
|+'''Dissemination of Legionella bacteria'''
|
'''AEROSOLISATION'''
|

The most widely accepted theory for Legionella transmission is that the organism is aerosolised from a water distribution system and is inhaled as droplets of respirable size. Aerosolisation may affect persons outside as well as inside a building.
 
|-
|
'''DIRECT INSTALLATION'''
|

Respiratory therapy devices have the potential to disseminate legionellae by delivering gases at high temperatures and volumes, and by generating concentrated aerosols, enabling them to bypass the normal defence mechanisms of the respiratory system.
 
|-
|
'''INGESTION'''
|

The fact that diarrhoea is one of the symptoms of Legionnaires’ disease suggests the gastro-intestinal tract as the source in some cases. After infection via this route, the bacteria may spread to the respiratory tract, thereby causing Legionnaires’ disease.
 
|-
|
'''ASPIRATION'''
|

Another well documented mode of transmission that effectively gets bacteria into the lungs is aspiration (a “choking process” that often occur during drinking, swallowing or dlearing the throat, and during respiratory therapy). Evidence suggests that it may be a more common mode for Legionella dissemination than previously believed although it has not been widely described in the literature.<blockquote>

'''REMEMBER!'''

Never presume that you cannot get Legionnaires’ disease

from drinking water containing Legionella.</blockquote>

|}
[[File:Influence of temperature on Legionella growth (Freije 1996).png|alt=Influence of temperature on Legionella growth|none|thumb|604x604px|Influence of temperature on Legionella growth <ref name=":0" />]]

====='''INFECTION AND HOST SUSCEPTIBILITY'''=====
Infections caused by Legionella species are collectively known as ''legionellosis'' and include Legionnaires’ disease and Pontiac fever. Subclinical (asymptomatic) infections have been reported. Legionellosis occurs worldwide, in people of all ages and race groups, with no evidence of person-to-person spread of infection. It is most common in summer and autumn months. The incidence of legionellosis varies from country to country and from region to region. Recently, an increase in the worldwide incidence of reported legionellosis cases has become evident. This may be explained by the availability of improved diagnostic and testing methods, increased awareness of the symptoms and improved surveillance. However legionellosis, especially sporadic cases, is still not always reported to public health authorities, making it difficult to estimate its true incidence.

The mode of transmission, inoculum size, particle size and host susceptibility influence the severity of infection. Approximately half of the currently known Legionella species are implicated in disease, but ''pneumophila'' is still considered to be the causative agent in about 80% of diagnosed cases. However, this picture might change as the number of available diagnostic tests increases – it is thus important to regard all legionellae a potentially pathogenic until proven otherwise.

==Section 3==
===LEGIONELLA INFECTIONS===
Infections caused by Legionella species are collectively known as legionellosis and include Legionnaires’ disease and Pontiac fever.1,2 Subclinical infections have been reported. Legionella infections occur worldwide in people of all ages and race groups with no evidence of person-to-person spread of infection.3,4

===LEGIONNAIRES’ DISEASE===
Legionnaires’ disease (LD) is a severe multisystem disease with pneumonia as the most predominant clinical finding. Clinical features are similar to those of other pneumonias, making it difficult to diagnose.5,6 Symptoms range from a mild cough and slight fever to a coma with widespread pulmonary infiltrates and multisystem failure. Survivors usually recover completely although lung fibrosis and neurological abnormalities may persist in some cases. LD has a low attack rate but the mortality rate is high.

Legionnaires’ disease outbreaks occur frequently all over the world. In the United States, Legionnaires’ disease is considered to be fairly common and legionellae are among the top three causes of sporadic, community-acquired pneumonia. However, many cases are still not reported, as Legionnaires’ disease is difficult to distinguish from other forms of pneumonia. Although only approximately 1,000 cases are reported to the Centers for Disease Control and Prevention (CDC), it is estimated that over 25,000 cases occur every year, causing more than 4,000 deaths.

Despite this, only one outbreak has been reported in South Africa to date. However, previous South African studies indicated antibody levels to L pneumophila in 65% of healthy blood donors, 36% of healthy mineworkers, 10% of healthy factory workers and 16% of hospitalised pneumonia patients.7,8 One study reported seroconverion to L.

pneumophila in 9% of patients hospitalised between 1987 and 1988 with symptoms of community-acquired pneumonia.9

 
[[File:Hillside figure 3.1.jpg|thumb|420x420px|Figure 3.1 Legionella pathology|alt=|center]]

Figure 3.1 Legionella pathology
===RISK FACTORS===
In order for LD to occur, the host must be susceptible to infection. Older people (above 50 years of age) are more commonly infected. Men are more likely to be infected (ratio 3:1) but the racial distribution is usually consistent with that of the population involved.10 Table 3.1 lists the most common risk factors.

Table 3.1 Risk factors for development of Legionnaires’ disease

Patient demographics Smoking Chronic pulmonary disease Immunosuppression Renal transplantation Renal dialysis Alcohol ingestion Age > 50 years Male

Environmental risks Exposure to construction activities Exposure to air conditioning systems Exposure to home air conditioning Travelling and accommodation in hotels Potable water Hospitalization

Source: Winn 1984 10

===SYMPTOMS===
Legionnaires’ disease presents with a broad spectrum of symptoms, ranging from mild cough and low fever to stupor, respiratory and multi organ failure. Pneumonia is the predominant clinical finding. Early symptoms are mainly non-specific and include fever, malaise, myalgias, anorexia and headache.6,11 The temperature often exceeds 40°C and the patient may present with a slightly productive cough. Chest pain, occasionally pleuritic, can be prominent and when coupled with hemoptysis, may mistakenly suggest pulmonary emboli. Gastrointestinal symptoms (watery stools) are prominent, especially diarrhoea, which occurs in 20-40% of cases. Relative bradycardia has been over-

emphasised as a diagnostic finding but is often seen in elderly patients with advanced pneumonia. Hyponatremia (serum sodium concentration ≥ 130 mmol/l) occurs more frequently in Legionnaires’ disease than in other pneumonias.

Extrapulmonary Legionnaires’ disease is rare but the clinical manifestations are often dramatic. These infections can easily be overlooked since the degree of suspicion is generally low in these cases. Legionella has been implicated in cases of sinusitis, cellulitis, pancreatitis, peritonitis and pyelonephritis. The most common extrapulmonary site of infection is the heart. There have been numerous reports of myocarditis, pericarditis, postcardiotomy syndrome and prosthetic valve endocarditis. In most cases there is no pneumonia symptoms present. Wound infections have also been reported.11

===INCUBATION PERIOD===
LD has an incubation period (the time it takes for symptoms to appear after exposure) of 2 – 10 days. The onset of symptoms may be sudden or gradual.

===DIAGNOSIS===
There are no reliable distinguishing clinical features to distinguish LD from pneumonia caused by other etiologic agents. However, there are some clinical clues to assist in the diagnosis (Table 3.2).6

Table 3.2 Clinical clues to Legionnaires’ disease

CLUE EXAMPLE

PATIENT HISTORY AND PHYSICAL EXAMINATION

Presence of an epidemic or documented source of

infection

Family, friends or associates with similar infection and exposure

Prominent neurologic or gastrointestinal symptoms

Pneumonia with confusion, nausea and vomiting

Non-response to aminoglycosides or beta-lactam

antibiotics

Worsening condition after 5 days on antibiotics

LABORATORY RESULTS OF PATIENT

Gram stain of sputum with many neutrophils but no

bacteria

Laboratory reports showing many neutrophils and few normal flora or no bacteria

Nodular peripheral infiltrates in chest radiographs Progression of unilateral opacities to bilateral nodular infiltrates over several days

It is important to remember that a clinical diagnosis of LD always has to be confirmed with specialised laboratory tests. As not all laboratories are equipped to perform these tests routinely, the tests have to be specifically requested by the physician. Table 3.3 highlights some of the most commonly used laboratory tests.12

· Culture of Legionella organisms from clinical samples is still the gold standard for diagnosing LD. The technique is highly specific, provided appropirate samples are used, and about 1.5 to 3 times more sensitive than immunofluorescence. Transtracheal aspirates are best for culture, but sputum, bronchial aspirates, pleural exudates, lung biopsies as well as wound swabs and even autopsy material have been used successfully.11 Disadvantages of the culturing of legionellae for diagnostic purposes include possible inhibition by non-legionellae organisms present in the sample, slow growth and difficulties in distinguishing legionellae from other organisms on solid media. These factors must be taken into account when choosing a laboratory to test clinical samples for LD.

· Immunofluorescence is useful to detect antigens (direct immunofluorescence) or antibodies (indirect immunofluorescence) in clinical samples in cases where culture is not possible. Cross reactions with organisms other than Legionella in the direct immunofluorescence (DFA) test may cause false positive results, making accurate

interpretation of the results essential.11,13 Indirect immunofluorescence (IFA) is the most specific of the currently available serological tests for LD. It is reproducible, sensitive and specific for the diagnosis of especially L. pneumophila infections, but may be affected by several factors, including the method of antigen preparation, method of antigen fixation during preparation of the reagent, the class of immunoglobulin it is designed to detect and strain differences.14,15

· The Legionella Urinary Antigen test5 is a relatively inexpensive and rapid diagnostic test, but only detects infections caused by L pneumophila Serogroup 1. The test is commercially available as a radioimmunoassay (RIA) or an enzyme linked immunosorbent assay (ELISA). An advantage of this test is the relative ease with which urine samples can be obtained, especially in patients with a non-productive cough. Legionella antigens may persist in the urine of some patients for as long as one year.

· Serological tests are useful for epidemiologic studies but less valuable for physicians. Diagnosis by serology is based on a fourfold rise in antibody titre to ≥ 1:128 in paired samples (from the acute and convalescent stage of disease).13,15 However, the antibody response may not be detectable until 1-3 months after onset of illness. Single titres of ≥1:256 during convalescence in pneumonia patients is suggestive of legionellosis. Antibody screening should include both IgG and IgM because some patients may only have an IgM response.5

· Assays based on the polymerase chain reaction (PCR) have been used to detect legionellae in urine, broncho-alveolar lavage fluid and sputum. These tests are highly specific but not more sensitive than culture and are much more expensive to perform. Limitations of PCR tests include the possible presence of certain “PCR inhibitors” in sputum and blood samples. The major advantage of PCR is the rapidity of the test and the ability to detect species other than L pneumophila. PCR is not used routinely for the clinical diagnosis of LD.

Table 3.3 Sensitivity and specificity of laboratory tests for the diagnosis of Legionnaires’ disease

TEST SENSITIVITY (%) SPECIFICITY (%)

Culture from clinical samples 80 100

Direct immunofluorescence (DFA) 33-70 96-99

Indirect immunofluorescence (IFA) 40-60 96-99

Urinary antigen detection 70 100

Source: Stout and Yu, 1997

===3.5 HISTOLOGY===
Pulmonary lesions usually consist of a mixture of neutrophils and macrophages, fibrin, proteinaceous material and red blood cells. Neutrophils and macrophages are often present in the centre of a lesion with mainly macrophages around the periphery.

Intracellular bacteria are present in both neutrophils and macrophages. Further away from the site of acute inflammation, bacteria are mainly seen inside the macrophages.10

Figure 3.3 Histological section of lung of Legionnaires disease patient

===3.6 CHEST RADIOGRAPHS===
Radiographic features in Legionnaires’ disease are mostly non-specific, and absent in Pontiac fever. Abnormalities occur from the third day post infection in most Legionnaires’ disease patients and usually do not correlate well with the severity of illness.11 However, the abnormalities correlate with the presence of the Legionella bacterium in sputum. The time required to show clearing of infiltrates on radiographs is variable and may range from 1-4 months. Some patients show diffuse alveolar damage. In the majority of patients with Legionnaires’ disease:

· Initial involvement is unilateral, predominantly in the lower lobe

· Bilateral involvement has been described

· Initial densities are poorly marginated, homogenous, rounded, occur either on the periphery or in the centre of the lung and may be mistaken for pulmonary infarction

· Pulmonary densities enlarge during later stages of disease

· Pulmonary densities have a typical ground glass appearance or dense consolidation

· Total opacification of the lung may occur

· Pleural effusions are present in 24-63% of cases caused by L pneumophila

· Pleural effusions are uncommon in L micdadei infections

· Hilar adenopathy seldom occurs

· Cavitation may occur in immunocompromised patients

· Cavitation rarely occurs in L micdadei infections

Figure 3.4 Chest radiograph of Legionnaires’ disease patient

===3.7 TREATMENT===
Treatment of LD requires the use of antibiotics. However, many antibiotics effective against other bacterial pneumonias are ineffective against Legionella as these drugs do not penetrate the pulmonary cells (alveolar macrophages) where infectious Legionella bacteria thrive.

Erythromycin was historically the drug of choice for the treatment of Legionnaires’ disease, but the newer macrolides (azithromycin) and quinolones (ciprofloxacin, levofloxacin, moxifloxacin, gemifloxacin, trovofloxacin have superior in vitro activity and greater intracellular and lung-tissue penetration.12 Other agents that have been shown to be effective include tetracycline, doxycycline, minocycline, trimethoprim- sulfamethoxazole.12 Rifampin is recommended as part of combination therapy with a macrolide or a quinolone for patients who are severely ill. The total duration of therapy is usually 10-14 days; however a 21-day course may be needed for immuno-compromised patients or those with extensive evidence of disease on chest radiographs.12

When LD patients are treated with appropriate antibiotics near the onset of disease, the prognosis is usually very good, especially if there is no underlying illness compromising the immune system. For patients with compromised immune systems, including transplant patients, any delay of appropriate treatment may result in complications, prolonged hospitalisation and death. However after successful treatment and hospital discharge, many patients still experience fatigue, loss of energy and difficulty concentrating. These symptoms may persist for several months, but complete recovery usually occurs within one year.

===PONTIAC FEVER===
Pontiac fever is an acute, self-limiting, flu-like illness without symptoms of pneumonia. The first outbreak of Pontiac fever was reported in Pontiac, Michigan, in 1968.16

It is characterised by high fever, chills, myalgia and malaise but without the pneumonia or cough typical of Legionnaires’ disease. Some authors suggest that it is a hypersensitivity pneumonitis, caused either by infection with a free-living amoeba called Acanthamoeba filled with legionellae or as a result of a toxic reaction to the organism. The incubation period is short, ranging from 1 – 3 days, and the attack rate high, exceeding 90% in some cases. The fatality rate is low.

Pontiac fever symptoms usually resolve spontaneously within one week, only symptomatic treatment is needed and the chest radiograph is clear. There is no evidence of secondary spread of the infection in Pontiac fever. Diagnosis can only be made by seroconversion, which may be delayed for up to 6 weeks after onset of symptoms. Cases of PF have been linked to L pneumophila, L feelei and L anisa. Complete recovery usually occurs in 2 – 5 days without medical attention

==References==
<references />
[[Category:Legionella Control]]
[[Category:Infection Prevention and Control]]
[[Category:Water Distributions Systems]]

Legionella Control

2020-10-22T11:52:00Z

Tmojanaga: /* RISK FACTORS */

{{Stub}}
{{Anchor|Section1}}
==Section 1==
{{Expand}}

==Section 2==

==='''THE CHAIN OF INFECTION'''===
The mere presence of legionellae in a water distribution system does not necessarily imply a human health risk. For human infection to occur, certain conditions are necessary. These conditions are referred to as the “chain of infection” consisting of six links. All the links have to be present for disease to occur ([[#Legionella-Chain_of_Infection|Diagram: Chain of infection]] ). The first link, the pathogen, was discussed in [[#Section1|Section 1]].

{{Anchor|Legionella-Chain_of_Infection}}
[[File:Chain of infection.png|alt=Chain of infection|none|thumb|Chain of infection|450x450px]]

==='''SOURCES AND RESERVOIRS'''===
Legionellae are natural inhabitants of water, found a wide range of habitats. They are ubiquitous in streams, lakes and rivers. They also survive in dust, soil and mud. In fact, one of the species, ''Legionella longbeacheae'', is so often isolated from potting soil in Australia that soil has been suggested as the natural habitat of this particular species.<ref>Dennis PJ (1993). Potable water systems: insights into control. In: Barbaree JM, Breiman RF and Dufour AP (eds). Legionella: Current status and emerging perspectives. American Society for Microbiology, Washington DC. Pp 223-225.</ref>

{{Anchor|Natural sources of Legionella}}
[[File:Natural sources of Legionella.png|alt=Natural sources of Legionella|none|thumb|Chain of infection|450x450px]]

Legionellae from these natural environments can be transmitted to man-made water systems by various means. For example, from raw water, during water treatment, as part of post-treatment after-growths within water distribution systems, during building and construction activities and during plumbing repair.<ref>Colbourne JS and Dennis PJ (1985). Distribution and persistence of Legionella in water systems. ''Microbiol. Sc.'' '''2''': 40-43.</ref>

Once established, they can persist in the water supply for long periods of time and are difficult to eradicate. Therefore, their presence must be considered in all aspects of the design, operation and maintenance of buildings. For this to be effective, cooperation between engineers, occupational health practitioners and microbiologists is essential.

Figure 2.3 Man-made sources of Legionella

=====Water sources that provide optimal conditions for Legionella growth can be separated into those containing “non-potable” and those that contain “potable” water. '''Non-potable water distribution systems'''=====

Heat rejection devices like cooling towers, evaporative condensers and HVAC (heating, ventilation and air-conditioning) systems are often implicated as sources of legionellosis. They contain reservoirs filled with warm, recirculating water that makes them ideal for the growth, amplification and dissemination of micro organisms (including Legionella). In a typical water-cooled system air in induced through or blown over, packing material down which water, circulating from a pond under the packing, is allowed to fall by gravity, producing a large wetted surface that cools the falling water.

The constant fall of water through the tower, the large area of the basin, fill, pipes and heat exchanger, the warm temperature of the water, the high relative humidity and high organic content within these devices provide conditions that favour contamination by algae, protozoa, fungi and bacteria. The risk is increased further by the open nature of the systems, excessive aeration and the constant addition of fresh water to make up for water lost through evaporation.

In systems that are not regularly cleaned, sludge accumulates in the reservoir and slime adheres to water covered surfaces, resulting in the presence of large concentrations of micro-organisms, including legionellae, on these surfaces. In addition, water temperatures below 60°C, the age and configuration of the system, the pH of the water and the presence of certain metals may also increase the risk of contamination.

Water derived from municipal supplies but subsequently stored in cisterns, or conditioned prior to heating, is considered non-potable due to the deterioration in chemical and bacteriological quality during storage. Colonisation of such non-potable sources inside large buildings, such as hotels, factories or hospitals, may be a major cause of legionellosis.<ref>Muraca PW, Stout JE, Yu VL and Yee YC (1988). Mode of transmission of ''Legionella pneumophila''. A critical review. ''Am. J. Hyg. Assoc.'' '''49''': 584-590.</ref><ref>Yamamoto H, Sugiura M, Kusunoki S, Ezaki T, Ikedo M and Yabuuchi E (1992). Factors stimulating propagation of legionellae in cooling tower water. ''Appl. Environ. Microbiol.'' '''58''': 1394-1397</ref><ref name=":0">Freije MR (1996). Legionella control in healthcare facilities: A guide for minimising risk. HC Information Resources, Inc. United States of America. P 8</ref>

====='''Potable (domestic) water distribution systems'''=====
Legionellae are often present in potable water supplies, especially in the hot water sections of these systems. The organisms may enter potable water supplies from the main source, even from municipal water, and survive standard treatment protocols because most municipal water systems are not routinely screened for the presence of legionellae and the organisms are chlorine tolerant. Once inside the system, they find a suitable environment to multiply and are usually very difficult to eradicate.

Legionella levels can rise from very low to very high within short periods of time. The factors that give rise to these fluctuations are not well understood and often very hard to determine. These factors include the age and configuration of the pipes, the degree of scaling and sediment and the potential for biofilm formation within the system increase the risk of contamination. Water temperatures of 25 – 42°C, stagnation and the presence of certain free-living amoebae capable of supporting the intracellular growth of legionellae are often mentioned as amplifying factors in published reports. The biofilm and scale that form on surfaces in water distribution systems provide nutrients for legionellae and protect them from hot water and disinfectants. Some materials used in these systems, for example neoprene washers, are more readily colonised than others (See [[Legionella Control#Materials used in the construction of potable water lines and fixtures|Table]]). Building location may also play a role in the colonisation of potable water with legionellae.

Hot water tanks are often colonised with legionellae, especially at the bottom where a warm zone may develop and scale and sediment accumulate.<ref>MarrieTJ, Haldane D, Bezanson G and Peppard R (1992). Each water outlet is a unique ecological niche for ''Legionella pneumophila''. ''Epid. Infect.'' '''108''': 264-270</ref> Hot water piping, especially dead-legs, presents an additional risk as legionellae thrive in stagnant water.

====='''Soil'''=====
Outdoors, the soil may be contaminated through contact with Legionella-polluted water and become a source of airborne bacteria during earth moving operations, such as construction work.
{| class="wikitable"
|+{{Anchor|Materials used in the construction of potable water lines and fixtures}}'''Materials used in the construction of potable water lines and fixtures'''
|
'''Very good'''
|
Copper
|-
|
'''Good'''
|

Neoprene

Other synthetic materials
|-
|
'''Reasonable'''
|
Steel
|-
|
'''Not recommended'''
|
Rubber

Plastics
|}

===='''Amplification'''====
Legionellae are usually present in low numbers in natural sources. However, certain factors present in man-made reservoirs can promote Legionella growth and amplification. To improve our understanding of Legionella, its potential to cause disease and how to better control the organisms in water systems, we must understand these conditions. The most important factors amplifying Legionella numbers in man-made reservoirs are listed in the table [[Legionella Control#Amplifying factors for Legionella in man-made sources and reservoirs.|Amplifying factors for Legionella in man-made sources and reservoirs.]]
'''Remember'''
Temperature data is usually based on laboratory studies and is not from actual system (piping) studies, which makes it even less reliable to use for Legionella control. System temperature on its own should therefore not be relied upon for Legionella control, because the so-called “system temperature” rarely indicates one uniform temperature throughout the entire system. Therefore, maintaining the system temperature does not guarantee Legionella control. Also, in plumbing systems, especially larger and/or more complex piping systems, legionellae have been shown to survive at even higher temperatures due to biofilm, dead-legs, and other complexities. It has been suggested that potable water systems be operated at temperatures as high as possible but take into account the risk of scalding injuries and energy conservation requirements.
{| class="wikitable"
|+{{Anchor|Amplifying factors for Legionella in man-made sources and reservoirs}}'''Amplifying factors for Legionella in man-made sources and reservoirs'''
|
'''TEMPERATURE'''
|

Legionellae can survive over a wide range of temperatures (20 – 60°C) with an optimum growth temperature of 37 – 45°C as illustrated in the figure [[Legionella Control#Natural sources of Legionella|Natural sources of Legionella]] 
|-
|
'''pH'''
|

Legionellae can survive and multiply at a pH of 5.0 – 8.5 
|-
|
'''STAGNATION'''
|

The presence of stagnant water in distribution systems increases the risk of Legionella contamination 
|-
|
'''WATER TREATMENT'''
|

The type of water treatment used may affect the numbers of legionellae present in a distribution system 
|-
|
'''DISINFECTANTS'''
|

The type, concentration and persistence of residual disinfectants in the system may affect the numbers and types of legionellae present 
|-
|
'''CHEMICAL PARAMETERS'''
|

The presence of organic carbon and certain metals like zinc and copper may influence the risk of Legionella contamination 
|-
|
'''RELATIVE HUMIDITY'''
|

Legionellae survive best at 65% relative humidity (RH) and are least stable below 55% RH
|-
|
'''SLIME, ALGAE AND PROTOZOA'''
|

Amoebae, cyanobacteria and flavobacteria have been associated with the growth of legionellae in water distribution systems
 
|-
|
'''CORROSION PRODUCTS'''
|

Legionellae numbers are usually highest in sections where corrosion products are present
 
|-
|
'''CONSTRUCTION'''
|

Major construction has been associated with outbreaks of legionellosis.

It is believed that legionellae are released from the soil during excavations from where they can enter the cooling tower of the building, air intakes or water pipes, or may be inhaled directly. Another possibility is that, during construction, nutrients already present in dust and dirt may become more readily available for the organisms. In new buildings, plumbing should be flushed before use. Renovated buildings may contain stagnant water, that should be flushed out before returning the building to normal use.
 
|-
|
'''WATER PRESSURE'''
|

An increase in water pressure may send dirt into a system, providing a food source for the bacteria or may dislodge scale and sediment containing legionellae from pipes.
 
|-
|
'''BIOFILM, SCALE AND SEDIMENT'''
|

In hot water systems the concentrations of legionellae are usually highest within biofilms and at the openings of water outlets. Biofilms are widespread in nature, and on most man-made surfaces when submerged in water.

Legionellae are not only able to survive in biofilms, but can proliferate and attach to susceptible hosts like protozoa, depending on the type of material on which the biofilm is formed. For example:

· Legionellae have been found in biofilms forming on plastic surfaces in water piping systems. At a temperature of 40° they were shown to account for approximately 50% of the total biofilm flora;

· Legionellae are less likely to be present on copper surfaces because copper generally do not support biofouling. If present, the bacteria are usually found in small numbers;

· Metal plumbing components and associated corrosion products provide iron and other metals needed for Legionella, thereby supporting their survival and growth.

Sediment and scale assists in the growth of supporting organisms and free-living protozoa, increasing the risk of contamination by legionellae. For this reason, its presence often indicates a possibility of Legionella contamination.

Algal slime also provides a stable habitat for their survival and multiplication.
 
|}
'''Disinfectants'''
After disinfection, municipal water supplies usually travel several kilometers before it reaches the point of use. During this course, disinfectant residuals diminish and there is increasing exposure to potentially biofilm-contaminated piping. Although municipal water systems are required to be disinfected at their points of distribution to conform to existing standards for bacterial disinfection, these standards are based upon the absence of coliform bacteria and do not include any specific testing requirements for Legionella.

====='''Transmission'''=====
After growth and amplification of legionellae to potentially infectious levels, the next requirement in the chain of infection is to achieve transmission of the bacteria to a susceptible host. Modern technology like cooling towers used to recirculate water for air-conditioning and humidifying purposes and other ventilation systems can cause the formation and distribution of aerosols through which the organisms can spread. Transmission can also occur through direct installation, aspiration or ingestion (Table [[Legionella Control#Dissemination of Legionella bacteria|Dissemination of Legionella bacteria]]).
{| class="wikitable"
|+'''Dissemination of Legionella bacteria'''
|
'''AEROSOLISATION'''
|

The most widely accepted theory for Legionella transmission is that the organism is aerosolised from a water distribution system and is inhaled as droplets of respirable size. Aerosolisation may affect persons outside as well as inside a building.
 
|-
|
'''DIRECT INSTALLATION'''
|

Respiratory therapy devices have the potential to disseminate legionellae by delivering gases at high temperatures and volumes, and by generating concentrated aerosols, enabling them to bypass the normal defence mechanisms of the respiratory system.
 
|-
|
'''INGESTION'''
|

The fact that diarrhoea is one of the symptoms of Legionnaires’ disease suggests the gastro-intestinal tract as the source in some cases. After infection via this route, the bacteria may spread to the respiratory tract, thereby causing Legionnaires’ disease.
 
|-
|
'''ASPIRATION'''
|

Another well documented mode of transmission that effectively gets bacteria into the lungs is aspiration (a “choking process” that often occur during drinking, swallowing or dlearing the throat, and during respiratory therapy). Evidence suggests that it may be a more common mode for Legionella dissemination than previously believed although it has not been widely described in the literature.<blockquote>

'''REMEMBER!'''

Never presume that you cannot get Legionnaires’ disease

from drinking water containing Legionella.</blockquote>

|}
[[File:Influence of temperature on Legionella growth (Freije 1996).png|alt=Influence of temperature on Legionella growth|none|thumb|604x604px|Influence of temperature on Legionella growth <ref name=":0" />]]

====='''INFECTION AND HOST SUSCEPTIBILITY'''=====
Infections caused by Legionella species are collectively known as ''legionellosis'' and include Legionnaires’ disease and Pontiac fever. Subclinical (asymptomatic) infections have been reported. Legionellosis occurs worldwide, in people of all ages and race groups, with no evidence of person-to-person spread of infection. It is most common in summer and autumn months. The incidence of legionellosis varies from country to country and from region to region. Recently, an increase in the worldwide incidence of reported legionellosis cases has become evident. This may be explained by the availability of improved diagnostic and testing methods, increased awareness of the symptoms and improved surveillance. However legionellosis, especially sporadic cases, is still not always reported to public health authorities, making it difficult to estimate its true incidence.

The mode of transmission, inoculum size, particle size and host susceptibility influence the severity of infection. Approximately half of the currently known Legionella species are implicated in disease, but ''pneumophila'' is still considered to be the causative agent in about 80% of diagnosed cases. However, this picture might change as the number of available diagnostic tests increases – it is thus important to regard all legionellae a potentially pathogenic until proven otherwise.

==Section 3==
===LEGIONELLA INFECTIONS===
Infections caused by Legionella species are collectively known as legionellosis and include Legionnaires’ disease and Pontiac fever.1,2 Subclinical infections have been reported. Legionella infections occur worldwide in people of all ages and race groups with no evidence of person-to-person spread of infection.3,4

===LEGIONNAIRES’ DISEASE===
Legionnaires’ disease (LD) is a severe multisystem disease with pneumonia as the most predominant clinical finding. Clinical features are similar to those of other pneumonias, making it difficult to diagnose.5,6 Symptoms range from a mild cough and slight fever to a coma with widespread pulmonary infiltrates and multisystem failure. Survivors usually recover completely although lung fibrosis and neurological abnormalities may persist in some cases. LD has a low attack rate but the mortality rate is high.

Legionnaires’ disease outbreaks occur frequently all over the world. In the United States, Legionnaires’ disease is considered to be fairly common and legionellae are among the top three causes of sporadic, community-acquired pneumonia. However, many cases are still not reported, as Legionnaires’ disease is difficult to distinguish from other forms of pneumonia. Although only approximately 1,000 cases are reported to the Centers for Disease Control and Prevention (CDC), it is estimated that over 25,000 cases occur every year, causing more than 4,000 deaths.

Despite this, only one outbreak has been reported in South Africa to date. However, previous South African studies indicated antibody levels to L pneumophila in 65% of healthy blood donors, 36% of healthy mineworkers, 10% of healthy factory workers and 16% of hospitalised pneumonia patients.7,8 One study reported seroconverion to L.

pneumophila in 9% of patients hospitalised between 1987 and 1988 with symptoms of community-acquired pneumonia.9
[[File:Hillside figure 3.1.jpg|left|thumb|420x420px|Figure 3.1 Legionella pathology]]

Figure 3.1 Legionella pathology

===RISK FACTORS===
In order for LD to occur, the host must be susceptible to infection. Older people (above 50 years of age) are more commonly infected. Men are more likely to be infected (ratio 3:1) but the racial distribution is usually consistent with that of the population involved.10 Table 3.1 lists the most common risk factors.

Table 3.1 Risk factors for development of Legionnaires’ disease

Patient demographics Smoking Chronic pulmonary disease Immunosuppression Renal transplantation Renal dialysis Alcohol ingestion Age > 50 years Male

Environmental risks Exposure to construction activities Exposure to air conditioning systems Exposure to home air conditioning Travelling and accommodation in hotels Potable water Hospitalization

Source: Winn 1984 10

===SYMPTOMS===
Legionnaires’ disease presents with a broad spectrum of symptoms, ranging from mild cough and low fever to stupor, respiratory and multi organ failure. Pneumonia is the predominant clinical finding. Early symptoms are mainly non-specific and include fever, malaise, myalgias, anorexia and headache.6,11 The temperature often exceeds 40°C and the patient may present with a slightly productive cough. Chest pain, occasionally pleuritic, can be prominent and when coupled with hemoptysis, may mistakenly suggest pulmonary emboli. Gastrointestinal symptoms (watery stools) are prominent, especially diarrhoea, which occurs in 20-40% of cases. Relative bradycardia has been over-

emphasised as a diagnostic finding but is often seen in elderly patients with advanced pneumonia. Hyponatremia (serum sodium concentration ≥ 130 mmol/l) occurs more frequently in Legionnaires’ disease than in other pneumonias.

Extrapulmonary Legionnaires’ disease is rare but the clinical manifestations are often dramatic. These infections can easily be overlooked since the degree of suspicion is generally low in these cases. Legionella has been implicated in cases of sinusitis, cellulitis, pancreatitis, peritonitis and pyelonephritis. The most common extrapulmonary site of infection is the heart. There have been numerous reports of myocarditis, pericarditis, postcardiotomy syndrome and prosthetic valve endocarditis. In most cases there is no pneumonia symptoms present. Wound infections have also been reported.11

===INCUBATION PERIOD===
LD has an incubation period (the time it takes for symptoms to appear after exposure) of 2 – 10 days. The onset of symptoms may be sudden or gradual.

===DIAGNOSIS===
There are no reliable distinguishing clinical features to distinguish LD from pneumonia caused by other etiologic agents. However, there are some clinical clues to assist in the diagnosis (Table 3.2).6

Table 3.2 Clinical clues to Legionnaires’ disease

CLUE EXAMPLE

PATIENT HISTORY AND PHYSICAL EXAMINATION

Presence of an epidemic or documented source of

infection

Family, friends or associates with similar infection and exposure

Prominent neurologic or gastrointestinal symptoms

Pneumonia with confusion, nausea and vomiting

Non-response to aminoglycosides or beta-lactam

antibiotics

Worsening condition after 5 days on antibiotics

LABORATORY RESULTS OF PATIENT

Gram stain of sputum with many neutrophils but no

bacteria

Laboratory reports showing many neutrophils and few normal flora or no bacteria

Nodular peripheral infiltrates in chest radiographs Progression of unilateral opacities to bilateral nodular infiltrates over several days

It is important to remember that a clinical diagnosis of LD always has to be confirmed with specialised laboratory tests. As not all laboratories are equipped to perform these tests routinely, the tests have to be specifically requested by the physician. Table 3.3 highlights some of the most commonly used laboratory tests.12

· Culture of Legionella organisms from clinical samples is still the gold standard for diagnosing LD. The technique is highly specific, provided appropirate samples are used, and about 1.5 to 3 times more sensitive than immunofluorescence. Transtracheal aspirates are best for culture, but sputum, bronchial aspirates, pleural exudates, lung biopsies as well as wound swabs and even autopsy material have been used successfully.11 Disadvantages of the culturing of legionellae for diagnostic purposes include possible inhibition by non-legionellae organisms present in the sample, slow growth and difficulties in distinguishing legionellae from other organisms on solid media. These factors must be taken into account when choosing a laboratory to test clinical samples for LD.

· Immunofluorescence is useful to detect antigens (direct immunofluorescence) or antibodies (indirect immunofluorescence) in clinical samples in cases where culture is not possible. Cross reactions with organisms other than Legionella in the direct immunofluorescence (DFA) test may cause false positive results, making accurate

interpretation of the results essential.11,13 Indirect immunofluorescence (IFA) is the most specific of the currently available serological tests for LD. It is reproducible, sensitive and specific for the diagnosis of especially L. pneumophila infections, but may be affected by several factors, including the method of antigen preparation, method of antigen fixation during preparation of the reagent, the class of immunoglobulin it is designed to detect and strain differences.14,15

· The Legionella Urinary Antigen test5 is a relatively inexpensive and rapid diagnostic test, but only detects infections caused by L pneumophila Serogroup 1. The test is commercially available as a radioimmunoassay (RIA) or an enzyme linked immunosorbent assay (ELISA). An advantage of this test is the relative ease with which urine samples can be obtained, especially in patients with a non-productive cough. Legionella antigens may persist in the urine of some patients for as long as one year.

· Serological tests are useful for epidemiologic studies but less valuable for physicians. Diagnosis by serology is based on a fourfold rise in antibody titre to ≥ 1:128 in paired samples (from the acute and convalescent stage of disease).13,15 However, the antibody response may not be detectable until 1-3 months after onset of illness. Single titres of ≥1:256 during convalescence in pneumonia patients is suggestive of legionellosis. Antibody screening should include both IgG and IgM because some patients may only have an IgM response.5

· Assays based on the polymerase chain reaction (PCR) have been used to detect legionellae in urine, broncho-alveolar lavage fluid and sputum. These tests are highly specific but not more sensitive than culture and are much more expensive to perform. Limitations of PCR tests include the possible presence of certain “PCR inhibitors” in sputum and blood samples. The major advantage of PCR is the rapidity of the test and the ability to detect species other than L pneumophila. PCR is not used routinely for the clinical diagnosis of LD.

Table 3.3 Sensitivity and specificity of laboratory tests for the diagnosis of Legionnaires’ disease

TEST SENSITIVITY (%) SPECIFICITY (%)

Culture from clinical samples 80 100

Direct immunofluorescence (DFA) 33-70 96-99

Indirect immunofluorescence (IFA) 40-60 96-99

Urinary antigen detection 70 100

Source: Stout and Yu, 1997

===3.5 HISTOLOGY===
Pulmonary lesions usually consist of a mixture of neutrophils and macrophages, fibrin, proteinaceous material and red blood cells. Neutrophils and macrophages are often present in the centre of a lesion with mainly macrophages around the periphery.

Intracellular bacteria are present in both neutrophils and macrophages. Further away from the site of acute inflammation, bacteria are mainly seen inside the macrophages.10

Figure 3.3 Histological section of lung of Legionnaires disease patient

===3.6 CHEST RADIOGRAPHS===
Radiographic features in Legionnaires’ disease are mostly non-specific, and absent in Pontiac fever. Abnormalities occur from the third day post infection in most Legionnaires’ disease patients and usually do not correlate well with the severity of illness.11 However, the abnormalities correlate with the presence of the Legionella bacterium in sputum. The time required to show clearing of infiltrates on radiographs is variable and may range from 1-4 months. Some patients show diffuse alveolar damage. In the majority of patients with Legionnaires’ disease:

· Initial involvement is unilateral, predominantly in the lower lobe

· Bilateral involvement has been described

· Initial densities are poorly marginated, homogenous, rounded, occur either on the periphery or in the centre of the lung and may be mistaken for pulmonary infarction

· Pulmonary densities enlarge during later stages of disease

· Pulmonary densities have a typical ground glass appearance or dense consolidation

· Total opacification of the lung may occur

· Pleural effusions are present in 24-63% of cases caused by L pneumophila

· Pleural effusions are uncommon in L micdadei infections

· Hilar adenopathy seldom occurs

· Cavitation may occur in immunocompromised patients

· Cavitation rarely occurs in L micdadei infections

Figure 3.4 Chest radiograph of Legionnaires’ disease patient

===3.7 TREATMENT===
Treatment of LD requires the use of antibiotics. However, many antibiotics effective against other bacterial pneumonias are ineffective against Legionella as these drugs do not penetrate the pulmonary cells (alveolar macrophages) where infectious Legionella bacteria thrive.

Erythromycin was historically the drug of choice for the treatment of Legionnaires’ disease, but the newer macrolides (azithromycin) and quinolones (ciprofloxacin, levofloxacin, moxifloxacin, gemifloxacin, trovofloxacin have superior in vitro activity and greater intracellular and lung-tissue penetration.12 Other agents that have been shown to be effective include tetracycline, doxycycline, minocycline, trimethoprim- sulfamethoxazole.12 Rifampin is recommended as part of combination therapy with a macrolide or a quinolone for patients who are severely ill. The total duration of therapy is usually 10-14 days; however a 21-day course may be needed for immuno-compromised patients or those with extensive evidence of disease on chest radiographs.12

When LD patients are treated with appropriate antibiotics near the onset of disease, the prognosis is usually very good, especially if there is no underlying illness compromising the immune system. For patients with compromised immune systems, including transplant patients, any delay of appropriate treatment may result in complications, prolonged hospitalisation and death. However after successful treatment and hospital discharge, many patients still experience fatigue, loss of energy and difficulty concentrating. These symptoms may persist for several months, but complete recovery usually occurs within one year.

===PONTIAC FEVER===
Pontiac fever is an acute, self-limiting, flu-like illness without symptoms of pneumonia. The first outbreak of Pontiac fever was reported in Pontiac, Michigan, in 1968.16

It is characterised by high fever, chills, myalgia and malaise but without the pneumonia or cough typical of Legionnaires’ disease. Some authors suggest that it is a hypersensitivity pneumonitis, caused either by infection with a free-living amoeba called Acanthamoeba filled with legionellae or as a result of a toxic reaction to the organism. The incubation period is short, ranging from 1 – 3 days, and the attack rate high, exceeding 90% in some cases. The fatality rate is low.

Pontiac fever symptoms usually resolve spontaneously within one week, only symptomatic treatment is needed and the chest radiograph is clear. There is no evidence of secondary spread of the infection in Pontiac fever. Diagnosis can only be made by seroconversion, which may be delayed for up to 6 weeks after onset of symptoms. Cases of PF have been linked to L pneumophila, L feelei and L anisa. Complete recovery usually occurs in 2 – 5 days without medical attention

==References==
<references />
[[Category:Legionella Control]]
[[Category:Infection Prevention and Control]]
[[Category:Water Distributions Systems]]

Legionella Control

2020-10-22T11:51:32Z

Tmojanaga: /* LEGIONNAIRES’ DISEASE */

{{Stub}}
{{Anchor|Section1}}
==Section 1==
{{Expand}}

==Section 2==

==='''THE CHAIN OF INFECTION'''===
The mere presence of legionellae in a water distribution system does not necessarily imply a human health risk. For human infection to occur, certain conditions are necessary. These conditions are referred to as the “chain of infection” consisting of six links. All the links have to be present for disease to occur ([[#Legionella-Chain_of_Infection|Diagram: Chain of infection]] ). The first link, the pathogen, was discussed in [[#Section1|Section 1]].

{{Anchor|Legionella-Chain_of_Infection}}
[[File:Chain of infection.png|alt=Chain of infection|none|thumb|Chain of infection|450x450px]]

==='''SOURCES AND RESERVOIRS'''===
Legionellae are natural inhabitants of water, found a wide range of habitats. They are ubiquitous in streams, lakes and rivers. They also survive in dust, soil and mud. In fact, one of the species, ''Legionella longbeacheae'', is so often isolated from potting soil in Australia that soil has been suggested as the natural habitat of this particular species.<ref>Dennis PJ (1993). Potable water systems: insights into control. In: Barbaree JM, Breiman RF and Dufour AP (eds). Legionella: Current status and emerging perspectives. American Society for Microbiology, Washington DC. Pp 223-225.</ref>

{{Anchor|Natural sources of Legionella}}
[[File:Natural sources of Legionella.png|alt=Natural sources of Legionella|none|thumb|Chain of infection|450x450px]]

Legionellae from these natural environments can be transmitted to man-made water systems by various means. For example, from raw water, during water treatment, as part of post-treatment after-growths within water distribution systems, during building and construction activities and during plumbing repair.<ref>Colbourne JS and Dennis PJ (1985). Distribution and persistence of Legionella in water systems. ''Microbiol. Sc.'' '''2''': 40-43.</ref>

Once established, they can persist in the water supply for long periods of time and are difficult to eradicate. Therefore, their presence must be considered in all aspects of the design, operation and maintenance of buildings. For this to be effective, cooperation between engineers, occupational health practitioners and microbiologists is essential.

Figure 2.3 Man-made sources of Legionella

=====Water sources that provide optimal conditions for Legionella growth can be separated into those containing “non-potable” and those that contain “potable” water. '''Non-potable water distribution systems'''=====

Heat rejection devices like cooling towers, evaporative condensers and HVAC (heating, ventilation and air-conditioning) systems are often implicated as sources of legionellosis. They contain reservoirs filled with warm, recirculating water that makes them ideal for the growth, amplification and dissemination of micro organisms (including Legionella). In a typical water-cooled system air in induced through or blown over, packing material down which water, circulating from a pond under the packing, is allowed to fall by gravity, producing a large wetted surface that cools the falling water.

The constant fall of water through the tower, the large area of the basin, fill, pipes and heat exchanger, the warm temperature of the water, the high relative humidity and high organic content within these devices provide conditions that favour contamination by algae, protozoa, fungi and bacteria. The risk is increased further by the open nature of the systems, excessive aeration and the constant addition of fresh water to make up for water lost through evaporation.

In systems that are not regularly cleaned, sludge accumulates in the reservoir and slime adheres to water covered surfaces, resulting in the presence of large concentrations of micro-organisms, including legionellae, on these surfaces. In addition, water temperatures below 60°C, the age and configuration of the system, the pH of the water and the presence of certain metals may also increase the risk of contamination.

Water derived from municipal supplies but subsequently stored in cisterns, or conditioned prior to heating, is considered non-potable due to the deterioration in chemical and bacteriological quality during storage. Colonisation of such non-potable sources inside large buildings, such as hotels, factories or hospitals, may be a major cause of legionellosis.<ref>Muraca PW, Stout JE, Yu VL and Yee YC (1988). Mode of transmission of ''Legionella pneumophila''. A critical review. ''Am. J. Hyg. Assoc.'' '''49''': 584-590.</ref><ref>Yamamoto H, Sugiura M, Kusunoki S, Ezaki T, Ikedo M and Yabuuchi E (1992). Factors stimulating propagation of legionellae in cooling tower water. ''Appl. Environ. Microbiol.'' '''58''': 1394-1397</ref><ref name=":0">Freije MR (1996). Legionella control in healthcare facilities: A guide for minimising risk. HC Information Resources, Inc. United States of America. P 8</ref>

====='''Potable (domestic) water distribution systems'''=====
Legionellae are often present in potable water supplies, especially in the hot water sections of these systems. The organisms may enter potable water supplies from the main source, even from municipal water, and survive standard treatment protocols because most municipal water systems are not routinely screened for the presence of legionellae and the organisms are chlorine tolerant. Once inside the system, they find a suitable environment to multiply and are usually very difficult to eradicate.

Legionella levels can rise from very low to very high within short periods of time. The factors that give rise to these fluctuations are not well understood and often very hard to determine. These factors include the age and configuration of the pipes, the degree of scaling and sediment and the potential for biofilm formation within the system increase the risk of contamination. Water temperatures of 25 – 42°C, stagnation and the presence of certain free-living amoebae capable of supporting the intracellular growth of legionellae are often mentioned as amplifying factors in published reports. The biofilm and scale that form on surfaces in water distribution systems provide nutrients for legionellae and protect them from hot water and disinfectants. Some materials used in these systems, for example neoprene washers, are more readily colonised than others (See [[Legionella Control#Materials used in the construction of potable water lines and fixtures|Table]]). Building location may also play a role in the colonisation of potable water with legionellae.

Hot water tanks are often colonised with legionellae, especially at the bottom where a warm zone may develop and scale and sediment accumulate.<ref>MarrieTJ, Haldane D, Bezanson G and Peppard R (1992). Each water outlet is a unique ecological niche for ''Legionella pneumophila''. ''Epid. Infect.'' '''108''': 264-270</ref> Hot water piping, especially dead-legs, presents an additional risk as legionellae thrive in stagnant water.

====='''Soil'''=====
Outdoors, the soil may be contaminated through contact with Legionella-polluted water and become a source of airborne bacteria during earth moving operations, such as construction work.
{| class="wikitable"
|+{{Anchor|Materials used in the construction of potable water lines and fixtures}}'''Materials used in the construction of potable water lines and fixtures'''
|
'''Very good'''
|
Copper
|-
|
'''Good'''
|

Neoprene

Other synthetic materials
|-
|
'''Reasonable'''
|
Steel
|-
|
'''Not recommended'''
|
Rubber

Plastics
|}

===='''Amplification'''====
Legionellae are usually present in low numbers in natural sources. However, certain factors present in man-made reservoirs can promote Legionella growth and amplification. To improve our understanding of Legionella, its potential to cause disease and how to better control the organisms in water systems, we must understand these conditions. The most important factors amplifying Legionella numbers in man-made reservoirs are listed in the table [[Legionella Control#Amplifying factors for Legionella in man-made sources and reservoirs.|Amplifying factors for Legionella in man-made sources and reservoirs.]]
'''Remember'''
Temperature data is usually based on laboratory studies and is not from actual system (piping) studies, which makes it even less reliable to use for Legionella control. System temperature on its own should therefore not be relied upon for Legionella control, because the so-called “system temperature” rarely indicates one uniform temperature throughout the entire system. Therefore, maintaining the system temperature does not guarantee Legionella control. Also, in plumbing systems, especially larger and/or more complex piping systems, legionellae have been shown to survive at even higher temperatures due to biofilm, dead-legs, and other complexities. It has been suggested that potable water systems be operated at temperatures as high as possible but take into account the risk of scalding injuries and energy conservation requirements.
{| class="wikitable"
|+{{Anchor|Amplifying factors for Legionella in man-made sources and reservoirs}}'''Amplifying factors for Legionella in man-made sources and reservoirs'''
|
'''TEMPERATURE'''
|

Legionellae can survive over a wide range of temperatures (20 – 60°C) with an optimum growth temperature of 37 – 45°C as illustrated in the figure [[Legionella Control#Natural sources of Legionella|Natural sources of Legionella]] 
|-
|
'''pH'''
|

Legionellae can survive and multiply at a pH of 5.0 – 8.5 
|-
|
'''STAGNATION'''
|

The presence of stagnant water in distribution systems increases the risk of Legionella contamination 
|-
|
'''WATER TREATMENT'''
|

The type of water treatment used may affect the numbers of legionellae present in a distribution system 
|-
|
'''DISINFECTANTS'''
|

The type, concentration and persistence of residual disinfectants in the system may affect the numbers and types of legionellae present 
|-
|
'''CHEMICAL PARAMETERS'''
|

The presence of organic carbon and certain metals like zinc and copper may influence the risk of Legionella contamination 
|-
|
'''RELATIVE HUMIDITY'''
|

Legionellae survive best at 65% relative humidity (RH) and are least stable below 55% RH
|-
|
'''SLIME, ALGAE AND PROTOZOA'''
|

Amoebae, cyanobacteria and flavobacteria have been associated with the growth of legionellae in water distribution systems
 
|-
|
'''CORROSION PRODUCTS'''
|

Legionellae numbers are usually highest in sections where corrosion products are present
 
|-
|
'''CONSTRUCTION'''
|

Major construction has been associated with outbreaks of legionellosis.

It is believed that legionellae are released from the soil during excavations from where they can enter the cooling tower of the building, air intakes or water pipes, or may be inhaled directly. Another possibility is that, during construction, nutrients already present in dust and dirt may become more readily available for the organisms. In new buildings, plumbing should be flushed before use. Renovated buildings may contain stagnant water, that should be flushed out before returning the building to normal use.
 
|-
|
'''WATER PRESSURE'''
|

An increase in water pressure may send dirt into a system, providing a food source for the bacteria or may dislodge scale and sediment containing legionellae from pipes.
 
|-
|
'''BIOFILM, SCALE AND SEDIMENT'''
|

In hot water systems the concentrations of legionellae are usually highest within biofilms and at the openings of water outlets. Biofilms are widespread in nature, and on most man-made surfaces when submerged in water.

Legionellae are not only able to survive in biofilms, but can proliferate and attach to susceptible hosts like protozoa, depending on the type of material on which the biofilm is formed. For example:

· Legionellae have been found in biofilms forming on plastic surfaces in water piping systems. At a temperature of 40° they were shown to account for approximately 50% of the total biofilm flora;

· Legionellae are less likely to be present on copper surfaces because copper generally do not support biofouling. If present, the bacteria are usually found in small numbers;

· Metal plumbing components and associated corrosion products provide iron and other metals needed for Legionella, thereby supporting their survival and growth.

Sediment and scale assists in the growth of supporting organisms and free-living protozoa, increasing the risk of contamination by legionellae. For this reason, its presence often indicates a possibility of Legionella contamination.

Algal slime also provides a stable habitat for their survival and multiplication.
 
|}
'''Disinfectants'''
After disinfection, municipal water supplies usually travel several kilometers before it reaches the point of use. During this course, disinfectant residuals diminish and there is increasing exposure to potentially biofilm-contaminated piping. Although municipal water systems are required to be disinfected at their points of distribution to conform to existing standards for bacterial disinfection, these standards are based upon the absence of coliform bacteria and do not include any specific testing requirements for Legionella.

====='''Transmission'''=====
After growth and amplification of legionellae to potentially infectious levels, the next requirement in the chain of infection is to achieve transmission of the bacteria to a susceptible host. Modern technology like cooling towers used to recirculate water for air-conditioning and humidifying purposes and other ventilation systems can cause the formation and distribution of aerosols through which the organisms can spread. Transmission can also occur through direct installation, aspiration or ingestion (Table [[Legionella Control#Dissemination of Legionella bacteria|Dissemination of Legionella bacteria]]).
{| class="wikitable"
|+'''Dissemination of Legionella bacteria'''
|
'''AEROSOLISATION'''
|

The most widely accepted theory for Legionella transmission is that the organism is aerosolised from a water distribution system and is inhaled as droplets of respirable size. Aerosolisation may affect persons outside as well as inside a building.
 
|-
|
'''DIRECT INSTALLATION'''
|

Respiratory therapy devices have the potential to disseminate legionellae by delivering gases at high temperatures and volumes, and by generating concentrated aerosols, enabling them to bypass the normal defence mechanisms of the respiratory system.
 
|-
|
'''INGESTION'''
|

The fact that diarrhoea is one of the symptoms of Legionnaires’ disease suggests the gastro-intestinal tract as the source in some cases. After infection via this route, the bacteria may spread to the respiratory tract, thereby causing Legionnaires’ disease.
 
|-
|
'''ASPIRATION'''
|

Another well documented mode of transmission that effectively gets bacteria into the lungs is aspiration (a “choking process” that often occur during drinking, swallowing or dlearing the throat, and during respiratory therapy). Evidence suggests that it may be a more common mode for Legionella dissemination than previously believed although it has not been widely described in the literature.<blockquote>

'''REMEMBER!'''

Never presume that you cannot get Legionnaires’ disease

from drinking water containing Legionella.</blockquote>

|}
[[File:Influence of temperature on Legionella growth (Freije 1996).png|alt=Influence of temperature on Legionella growth|none|thumb|604x604px|Influence of temperature on Legionella growth <ref name=":0" />]]

====='''INFECTION AND HOST SUSCEPTIBILITY'''=====
Infections caused by Legionella species are collectively known as ''legionellosis'' and include Legionnaires’ disease and Pontiac fever. Subclinical (asymptomatic) infections have been reported. Legionellosis occurs worldwide, in people of all ages and race groups, with no evidence of person-to-person spread of infection. It is most common in summer and autumn months. The incidence of legionellosis varies from country to country and from region to region. Recently, an increase in the worldwide incidence of reported legionellosis cases has become evident. This may be explained by the availability of improved diagnostic and testing methods, increased awareness of the symptoms and improved surveillance. However legionellosis, especially sporadic cases, is still not always reported to public health authorities, making it difficult to estimate its true incidence.

The mode of transmission, inoculum size, particle size and host susceptibility influence the severity of infection. Approximately half of the currently known Legionella species are implicated in disease, but ''pneumophila'' is still considered to be the causative agent in about 80% of diagnosed cases. However, this picture might change as the number of available diagnostic tests increases – it is thus important to regard all legionellae a potentially pathogenic until proven otherwise.

==Section 3==
===LEGIONELLA INFECTIONS===
Infections caused by Legionella species are collectively known as legionellosis and include Legionnaires’ disease and Pontiac fever.1,2 Subclinical infections have been reported. Legionella infections occur worldwide in people of all ages and race groups with no evidence of person-to-person spread of infection.3,4

===LEGIONNAIRES’ DISEASE===
Legionnaires’ disease (LD) is a severe multisystem disease with pneumonia as the most predominant clinical finding. Clinical features are similar to those of other pneumonias, making it difficult to diagnose.5,6 Symptoms range from a mild cough and slight fever to a coma with widespread pulmonary infiltrates and multisystem failure. Survivors usually recover completely although lung fibrosis and neurological abnormalities may persist in some cases. LD has a low attack rate but the mortality rate is high.

Legionnaires’ disease outbreaks occur frequently all over the world. In the United States, Legionnaires’ disease is considered to be fairly common and legionellae are among the top three causes of sporadic, community-acquired pneumonia. However, many cases are still not reported, as Legionnaires’ disease is difficult to distinguish from other forms of pneumonia. Although only approximately 1,000 cases are reported to the Centers for Disease Control and Prevention (CDC), it is estimated that over 25,000 cases occur every year, causing more than 4,000 deaths.

Despite this, only one outbreak has been reported in South Africa to date. However, previous South African studies indicated antibody levels to L pneumophila in 65% of healthy blood donors, 36% of healthy mineworkers, 10% of healthy factory workers and 16% of hospitalised pneumonia patients.7,8 One study reported seroconverion to L.

pneumophila in 9% of patients hospitalised between 1987 and 1988 with symptoms of community-acquired pneumonia.9
[[File:Hillside figure 3.1.jpg|left|thumb|420x420px|Figure 3.1 Legionella pathology]]

Figure 3.1 Legionella pathology

===RISK FACTORS===
In order for LD to occur, the host must be susceptible to infection. Older people (above 50 years of age) are more commonly infected. Men are more likely to be infected (ratio 3:1) but the racial distribution is usually consistent with that of the population involved.10 Table 3.1 lists the most common risk factors.

Table 3.1 Risk factors for development of Legionnaires’ disease

Patient demographics Smoking Chronic pulmonary disease Immunosuppression Renal transplantation Renal dialysis Alcohol ingestion Age > 50 years Male

Environmental risks Exposure to construction activities Exposure to air conditioning systems Exposure to home air conditioning Travelling and accommodation in hotels Potable water Hospitalization

Source: Winn 1984 10

===SYMPTOMS===
Legionnaires’ disease presents with a broad spectrum of symptoms, ranging from mild cough and low fever to stupor, respiratory and multi organ failure. Pneumonia is the predominant clinical finding. Early symptoms are mainly non-specific and include fever, malaise, myalgias, anorexia and headache.6,11 The temperature often exceeds 40°C and the patient may present with a slightly productive cough. Chest pain, occasionally pleuritic, can be prominent and when coupled with hemoptysis, may mistakenly suggest pulmonary emboli. Gastrointestinal symptoms (watery stools) are prominent, especially diarrhoea, which occurs in 20-40% of cases. Relative bradycardia has been over-

emphasised as a diagnostic finding but is often seen in elderly patients with advanced pneumonia. Hyponatremia (serum sodium concentration ≥ 130 mmol/l) occurs more frequently in Legionnaires’ disease than in other pneumonias.

Extrapulmonary Legionnaires’ disease is rare but the clinical manifestations are often dramatic. These infections can easily be overlooked since the degree of suspicion is generally low in these cases. Legionella has been implicated in cases of sinusitis, cellulitis, pancreatitis, peritonitis and pyelonephritis. The most common extrapulmonary site of infection is the heart. There have been numerous reports of myocarditis, pericarditis, postcardiotomy syndrome and prosthetic valve endocarditis. In most cases there is no pneumonia symptoms present. Wound infections have also been reported.11

===INCUBATION PERIOD===
LD has an incubation period (the time it takes for symptoms to appear after exposure) of 2 – 10 days. The onset of symptoms may be sudden or gradual.

===DIAGNOSIS===
There are no reliable distinguishing clinical features to distinguish LD from pneumonia caused by other etiologic agents. However, there are some clinical clues to assist in the diagnosis (Table 3.2).6

Table 3.2 Clinical clues to Legionnaires’ disease

CLUE EXAMPLE

PATIENT HISTORY AND PHYSICAL EXAMINATION

Presence of an epidemic or documented source of

infection

Family, friends or associates with similar infection and exposure

Prominent neurologic or gastrointestinal symptoms

Pneumonia with confusion, nausea and vomiting

Non-response to aminoglycosides or beta-lactam

antibiotics

Worsening condition after 5 days on antibiotics

LABORATORY RESULTS OF PATIENT

Gram stain of sputum with many neutrophils but no

bacteria

Laboratory reports showing many neutrophils and few normal flora or no bacteria

Nodular peripheral infiltrates in chest radiographs Progression of unilateral opacities to bilateral nodular infiltrates over several days

It is important to remember that a clinical diagnosis of LD always has to be confirmed with specialised laboratory tests. As not all laboratories are equipped to perform these tests routinely, the tests have to be specifically requested by the physician. Table 3.3 highlights some of the most commonly used laboratory tests.12

· Culture of Legionella organisms from clinical samples is still the gold standard for diagnosing LD. The technique is highly specific, provided appropirate samples are used, and about 1.5 to 3 times more sensitive than immunofluorescence. Transtracheal aspirates are best for culture, but sputum, bronchial aspirates, pleural exudates, lung biopsies as well as wound swabs and even autopsy material have been used successfully.11 Disadvantages of the culturing of legionellae for diagnostic purposes include possible inhibition by non-legionellae organisms present in the sample, slow growth and difficulties in distinguishing legionellae from other organisms on solid media. These factors must be taken into account when choosing a laboratory to test clinical samples for LD.

· Immunofluorescence is useful to detect antigens (direct immunofluorescence) or antibodies (indirect immunofluorescence) in clinical samples in cases where culture is not possible. Cross reactions with organisms other than Legionella in the direct immunofluorescence (DFA) test may cause false positive results, making accurate

interpretation of the results essential.11,13 Indirect immunofluorescence (IFA) is the most specific of the currently available serological tests for LD. It is reproducible, sensitive and specific for the diagnosis of especially L. pneumophila infections, but may be affected by several factors, including the method of antigen preparation, method of antigen fixation during preparation of the reagent, the class of immunoglobulin it is designed to detect and strain differences.14,15

· The Legionella Urinary Antigen test5 is a relatively inexpensive and rapid diagnostic test, but only detects infections caused by L pneumophila Serogroup 1. The test is commercially available as a radioimmunoassay (RIA) or an enzyme linked immunosorbent assay (ELISA). An advantage of this test is the relative ease with which urine samples can be obtained, especially in patients with a non-productive cough. Legionella antigens may persist in the urine of some patients for as long as one year.

· Serological tests are useful for epidemiologic studies but less valuable for physicians. Diagnosis by serology is based on a fourfold rise in antibody titre to ≥ 1:128 in paired samples (from the acute and convalescent stage of disease).13,15 However, the antibody response may not be detectable until 1-3 months after onset of illness. Single titres of ≥1:256 during convalescence in pneumonia patients is suggestive of legionellosis. Antibody screening should include both IgG and IgM because some patients may only have an IgM response.5

· Assays based on the polymerase chain reaction (PCR) have been used to detect legionellae in urine, broncho-alveolar lavage fluid and sputum. These tests are highly specific but not more sensitive than culture and are much more expensive to perform. Limitations of PCR tests include the possible presence of certain “PCR inhibitors” in sputum and blood samples. The major advantage of PCR is the rapidity of the test and the ability to detect species other than L pneumophila. PCR is not used routinely for the clinical diagnosis of LD.

Table 3.3 Sensitivity and specificity of laboratory tests for the diagnosis of Legionnaires’ disease

TEST SENSITIVITY (%) SPECIFICITY (%)

Culture from clinical samples 80 100

Direct immunofluorescence (DFA) 33-70 96-99

Indirect immunofluorescence (IFA) 40-60 96-99

Urinary antigen detection 70 100

Source: Stout and Yu, 1997

===3.5 HISTOLOGY===
Pulmonary lesions usually consist of a mixture of neutrophils and macrophages, fibrin, proteinaceous material and red blood cells. Neutrophils and macrophages are often present in the centre of a lesion with mainly macrophages around the periphery.

Intracellular bacteria are present in both neutrophils and macrophages. Further away from the site of acute inflammation, bacteria are mainly seen inside the macrophages.10

Figure 3.3 Histological section of lung of Legionnaires disease patient

===3.6 CHEST RADIOGRAPHS===
Radiographic features in Legionnaires’ disease are mostly non-specific, and absent in Pontiac fever. Abnormalities occur from the third day post infection in most Legionnaires’ disease patients and usually do not correlate well with the severity of illness.11 However, the abnormalities correlate with the presence of the Legionella bacterium in sputum. The time required to show clearing of infiltrates on radiographs is variable and may range from 1-4 months. Some patients show diffuse alveolar damage. In the majority of patients with Legionnaires’ disease:

· Initial involvement is unilateral, predominantly in the lower lobe

· Bilateral involvement has been described

· Initial densities are poorly marginated, homogenous, rounded, occur either on the periphery or in the centre of the lung and may be mistaken for pulmonary infarction

· Pulmonary densities enlarge during later stages of disease

· Pulmonary densities have a typical ground glass appearance or dense consolidation

· Total opacification of the lung may occur

· Pleural effusions are present in 24-63% of cases caused by L pneumophila

· Pleural effusions are uncommon in L micdadei infections

· Hilar adenopathy seldom occurs

· Cavitation may occur in immunocompromised patients

· Cavitation rarely occurs in L micdadei infections

Figure 3.4 Chest radiograph of Legionnaires’ disease patient

===3.7 TREATMENT===
Treatment of LD requires the use of antibiotics. However, many antibiotics effective against other bacterial pneumonias are ineffective against Legionella as these drugs do not penetrate the pulmonary cells (alveolar macrophages) where infectious Legionella bacteria thrive.

Erythromycin was historically the drug of choice for the treatment of Legionnaires’ disease, but the newer macrolides (azithromycin) and quinolones (ciprofloxacin, levofloxacin, moxifloxacin, gemifloxacin, trovofloxacin have superior in vitro activity and greater intracellular and lung-tissue penetration.12 Other agents that have been shown to be effective include tetracycline, doxycycline, minocycline, trimethoprim- sulfamethoxazole.12 Rifampin is recommended as part of combination therapy with a macrolide or a quinolone for patients who are severely ill. The total duration of therapy is usually 10-14 days; however a 21-day course may be needed for immuno-compromised patients or those with extensive evidence of disease on chest radiographs.12

When LD patients are treated with appropriate antibiotics near the onset of disease, the prognosis is usually very good, especially if there is no underlying illness compromising the immune system. For patients with compromised immune systems, including transplant patients, any delay of appropriate treatment may result in complications, prolonged hospitalisation and death. However after successful treatment and hospital discharge, many patients still experience fatigue, loss of energy and difficulty concentrating. These symptoms may persist for several months, but complete recovery usually occurs within one year.

===PONTIAC FEVER===
Pontiac fever is an acute, self-limiting, flu-like illness without symptoms of pneumonia. The first outbreak of Pontiac fever was reported in Pontiac, Michigan, in 1968.16

It is characterised by high fever, chills, myalgia and malaise but without the pneumonia or cough typical of Legionnaires’ disease. Some authors suggest that it is a hypersensitivity pneumonitis, caused either by infection with a free-living amoeba called Acanthamoeba filled with legionellae or as a result of a toxic reaction to the organism. The incubation period is short, ranging from 1 – 3 days, and the attack rate high, exceeding 90% in some cases. The fatality rate is low.

Pontiac fever symptoms usually resolve spontaneously within one week, only symptomatic treatment is needed and the chest radiograph is clear. There is no evidence of secondary spread of the infection in Pontiac fever. Diagnosis can only be made by seroconversion, which may be delayed for up to 6 weeks after onset of symptoms. Cases of PF have been linked to L pneumophila, L feelei and L anisa. Complete recovery usually occurs in 2 – 5 days without medical attention

==References==
<references />
[[Category:Legionella Control]]
[[Category:Infection Prevention and Control]]
[[Category:Water Distributions Systems]]

File:Hillside figure 3.1.jpg

2020-10-22T11:49:57Z

Tmojanaga:

Figure 3.1 of Chapter

Legionella Control

2020-10-21T07:56:47Z

Tmojanaga: /* References */ Sections

{{Stub}}
{{Anchor|Section1}}
==Section 1==
{{Expand}}

==Section 2==

==='''THE CHAIN OF INFECTION'''===
The mere presence of legionellae in a water distribution system does not necessarily imply a human health risk. For human infection to occur, certain conditions are necessary. These conditions are referred to as the “chain of infection” consisting of six links. All the links have to be present for disease to occur ([[#Legionella-Chain_of_Infection|Diagram: Chain of infection]] ). The first link, the pathogen, was discussed in [[#Section1|Section 1]].

{{Anchor|Legionella-Chain_of_Infection}}
[[File:Chain of infection.png|alt=Chain of infection|none|thumb|Chain of infection|450x450px]]

==='''SOURCES AND RESERVOIRS'''===
Legionellae are natural inhabitants of water, found a wide range of habitats. They are ubiquitous in streams, lakes and rivers. They also survive in dust, soil and mud. In fact, one of the species, ''Legionella longbeacheae'', is so often isolated from potting soil in Australia that soil has been suggested as the natural habitat of this particular species.<ref>Dennis PJ (1993). Potable water systems: insights into control. In: Barbaree JM, Breiman RF and Dufour AP (eds). Legionella: Current status and emerging perspectives. American Society for Microbiology, Washington DC. Pp 223-225.</ref>

{{Anchor|Natural sources of Legionella}}
[[File:Natural sources of Legionella.png|alt=Natural sources of Legionella|none|thumb|Chain of infection|450x450px]]

Legionellae from these natural environments can be transmitted to man-made water systems by various means. For example, from raw water, during water treatment, as part of post-treatment after-growths within water distribution systems, during building and construction activities and during plumbing repair.<ref>Colbourne JS and Dennis PJ (1985). Distribution and persistence of Legionella in water systems. ''Microbiol. Sc.'' '''2''': 40-43.</ref>

Once established, they can persist in the water supply for long periods of time and are difficult to eradicate. Therefore, their presence must be considered in all aspects of the design, operation and maintenance of buildings. For this to be effective, cooperation between engineers, occupational health practitioners and microbiologists is essential.

Figure 2.3 Man-made sources of Legionella

=====Water sources that provide optimal conditions for Legionella growth can be separated into those containing “non-potable” and those that contain “potable” water. '''Non-potable water distribution systems'''=====

Heat rejection devices like cooling towers, evaporative condensers and HVAC (heating, ventilation and air-conditioning) systems are often implicated as sources of legionellosis. They contain reservoirs filled with warm, recirculating water that makes them ideal for the growth, amplification and dissemination of micro organisms (including Legionella). In a typical water-cooled system air in induced through or blown over, packing material down which water, circulating from a pond under the packing, is allowed to fall by gravity, producing a large wetted surface that cools the falling water.

The constant fall of water through the tower, the large area of the basin, fill, pipes and heat exchanger, the warm temperature of the water, the high relative humidity and high organic content within these devices provide conditions that favour contamination by algae, protozoa, fungi and bacteria. The risk is increased further by the open nature of the systems, excessive aeration and the constant addition of fresh water to make up for water lost through evaporation.

In systems that are not regularly cleaned, sludge accumulates in the reservoir and slime adheres to water covered surfaces, resulting in the presence of large concentrations of micro-organisms, including legionellae, on these surfaces. In addition, water temperatures below 60°C, the age and configuration of the system, the pH of the water and the presence of certain metals may also increase the risk of contamination.

Water derived from municipal supplies but subsequently stored in cisterns, or conditioned prior to heating, is considered non-potable due to the deterioration in chemical and bacteriological quality during storage. Colonisation of such non-potable sources inside large buildings, such as hotels, factories or hospitals, may be a major cause of legionellosis.<ref>Muraca PW, Stout JE, Yu VL and Yee YC (1988). Mode of transmission of ''Legionella pneumophila''. A critical review. ''Am. J. Hyg. Assoc.'' '''49''': 584-590.</ref><ref>Yamamoto H, Sugiura M, Kusunoki S, Ezaki T, Ikedo M and Yabuuchi E (1992). Factors stimulating propagation of legionellae in cooling tower water. ''Appl. Environ. Microbiol.'' '''58''': 1394-1397</ref><ref name=":0">Freije MR (1996). Legionella control in healthcare facilities: A guide for minimising risk. HC Information Resources, Inc. United States of America. P 8</ref>

====='''Potable (domestic) water distribution systems'''=====
Legionellae are often present in potable water supplies, especially in the hot water sections of these systems. The organisms may enter potable water supplies from the main source, even from municipal water, and survive standard treatment protocols because most municipal water systems are not routinely screened for the presence of legionellae and the organisms are chlorine tolerant. Once inside the system, they find a suitable environment to multiply and are usually very difficult to eradicate.

Legionella levels can rise from very low to very high within short periods of time. The factors that give rise to these fluctuations are not well understood and often very hard to determine. These factors include the age and configuration of the pipes, the degree of scaling and sediment and the potential for biofilm formation within the system increase the risk of contamination. Water temperatures of 25 – 42°C, stagnation and the presence of certain free-living amoebae capable of supporting the intracellular growth of legionellae are often mentioned as amplifying factors in published reports. The biofilm and scale that form on surfaces in water distribution systems provide nutrients for legionellae and protect them from hot water and disinfectants. Some materials used in these systems, for example neoprene washers, are more readily colonised than others (See [[Legionella Control#Materials used in the construction of potable water lines and fixtures|Table]]). Building location may also play a role in the colonisation of potable water with legionellae.

Hot water tanks are often colonised with legionellae, especially at the bottom where a warm zone may develop and scale and sediment accumulate.<ref>MarrieTJ, Haldane D, Bezanson G and Peppard R (1992). Each water outlet is a unique ecological niche for ''Legionella pneumophila''. ''Epid. Infect.'' '''108''': 264-270</ref> Hot water piping, especially dead-legs, presents an additional risk as legionellae thrive in stagnant water.

====='''Soil'''=====
Outdoors, the soil may be contaminated through contact with Legionella-polluted water and become a source of airborne bacteria during earth moving operations, such as construction work.
{| class="wikitable"
|+{{Anchor|Materials used in the construction of potable water lines and fixtures}}'''Materials used in the construction of potable water lines and fixtures'''
|
'''Very good'''
|
Copper
|-
|
'''Good'''
|

Neoprene

Other synthetic materials
|-
|
'''Reasonable'''
|
Steel
|-
|
'''Not recommended'''
|
Rubber

Plastics
|}

===='''Amplification'''====
Legionellae are usually present in low numbers in natural sources. However, certain factors present in man-made reservoirs can promote Legionella growth and amplification. To improve our understanding of Legionella, its potential to cause disease and how to better control the organisms in water systems, we must understand these conditions. The most important factors amplifying Legionella numbers in man-made reservoirs are listed in the table [[Legionella Control#Amplifying factors for Legionella in man-made sources and reservoirs.|Amplifying factors for Legionella in man-made sources and reservoirs.]]
'''Remember'''
Temperature data is usually based on laboratory studies and is not from actual system (piping) studies, which makes it even less reliable to use for Legionella control. System temperature on its own should therefore not be relied upon for Legionella control, because the so-called “system temperature” rarely indicates one uniform temperature throughout the entire system. Therefore, maintaining the system temperature does not guarantee Legionella control. Also, in plumbing systems, especially larger and/or more complex piping systems, legionellae have been shown to survive at even higher temperatures due to biofilm, dead-legs, and other complexities. It has been suggested that potable water systems be operated at temperatures as high as possible but take into account the risk of scalding injuries and energy conservation requirements.
{| class="wikitable"
|+{{Anchor|Amplifying factors for Legionella in man-made sources and reservoirs}}'''Amplifying factors for Legionella in man-made sources and reservoirs'''
|
'''TEMPERATURE'''
|

Legionellae can survive over a wide range of temperatures (20 – 60°C) with an optimum growth temperature of 37 – 45°C as illustrated in the figure [[Legionella Control#Natural sources of Legionella|Natural sources of Legionella]] 
|-
|
'''pH'''
|

Legionellae can survive and multiply at a pH of 5.0 – 8.5 
|-
|
'''STAGNATION'''
|

The presence of stagnant water in distribution systems increases the risk of Legionella contamination 
|-
|
'''WATER TREATMENT'''
|

The type of water treatment used may affect the numbers of legionellae present in a distribution system 
|-
|
'''DISINFECTANTS'''
|

The type, concentration and persistence of residual disinfectants in the system may affect the numbers and types of legionellae present 
|-
|
'''CHEMICAL PARAMETERS'''
|

The presence of organic carbon and certain metals like zinc and copper may influence the risk of Legionella contamination 
|-
|
'''RELATIVE HUMIDITY'''
|

Legionellae survive best at 65% relative humidity (RH) and are least stable below 55% RH
|-
|
'''SLIME, ALGAE AND PROTOZOA'''
|

Amoebae, cyanobacteria and flavobacteria have been associated with the growth of legionellae in water distribution systems
 
|-
|
'''CORROSION PRODUCTS'''
|

Legionellae numbers are usually highest in sections where corrosion products are present
 
|-
|
'''CONSTRUCTION'''
|

Major construction has been associated with outbreaks of legionellosis.

It is believed that legionellae are released from the soil during excavations from where they can enter the cooling tower of the building, air intakes or water pipes, or may be inhaled directly. Another possibility is that, during construction, nutrients already present in dust and dirt may become more readily available for the organisms. In new buildings, plumbing should be flushed before use. Renovated buildings may contain stagnant water, that should be flushed out before returning the building to normal use.
 
|-
|
'''WATER PRESSURE'''
|

An increase in water pressure may send dirt into a system, providing a food source for the bacteria or may dislodge scale and sediment containing legionellae from pipes.
 
|-
|
'''BIOFILM, SCALE AND SEDIMENT'''
|

In hot water systems the concentrations of legionellae are usually highest within biofilms and at the openings of water outlets. Biofilms are widespread in nature, and on most man-made surfaces when submerged in water.

Legionellae are not only able to survive in biofilms, but can proliferate and attach to susceptible hosts like protozoa, depending on the type of material on which the biofilm is formed. For example:

· Legionellae have been found in biofilms forming on plastic surfaces in water piping systems. At a temperature of 40° they were shown to account for approximately 50% of the total biofilm flora;

· Legionellae are less likely to be present on copper surfaces because copper generally do not support biofouling. If present, the bacteria are usually found in small numbers;

· Metal plumbing components and associated corrosion products provide iron and other metals needed for Legionella, thereby supporting their survival and growth.

Sediment and scale assists in the growth of supporting organisms and free-living protozoa, increasing the risk of contamination by legionellae. For this reason, its presence often indicates a possibility of Legionella contamination.

Algal slime also provides a stable habitat for their survival and multiplication.
 
|}
'''Disinfectants'''
After disinfection, municipal water supplies usually travel several kilometers before it reaches the point of use. During this course, disinfectant residuals diminish and there is increasing exposure to potentially biofilm-contaminated piping. Although municipal water systems are required to be disinfected at their points of distribution to conform to existing standards for bacterial disinfection, these standards are based upon the absence of coliform bacteria and do not include any specific testing requirements for Legionella.

====='''Transmission'''=====
After growth and amplification of legionellae to potentially infectious levels, the next requirement in the chain of infection is to achieve transmission of the bacteria to a susceptible host. Modern technology like cooling towers used to recirculate water for air-conditioning and humidifying purposes and other ventilation systems can cause the formation and distribution of aerosols through which the organisms can spread. Transmission can also occur through direct installation, aspiration or ingestion (Table [[Legionella Control#Dissemination of Legionella bacteria|Dissemination of Legionella bacteria]]).
{| class="wikitable"
|+'''Dissemination of Legionella bacteria'''
|
'''AEROSOLISATION'''
|

The most widely accepted theory for Legionella transmission is that the organism is aerosolised from a water distribution system and is inhaled as droplets of respirable size. Aerosolisation may affect persons outside as well as inside a building.
 
|-
|
'''DIRECT INSTALLATION'''
|

Respiratory therapy devices have the potential to disseminate legionellae by delivering gases at high temperatures and volumes, and by generating concentrated aerosols, enabling them to bypass the normal defence mechanisms of the respiratory system.
 
|-
|
'''INGESTION'''
|

The fact that diarrhoea is one of the symptoms of Legionnaires’ disease suggests the gastro-intestinal tract as the source in some cases. After infection via this route, the bacteria may spread to the respiratory tract, thereby causing Legionnaires’ disease.
 
|-
|
'''ASPIRATION'''
|

Another well documented mode of transmission that effectively gets bacteria into the lungs is aspiration (a “choking process” that often occur during drinking, swallowing or dlearing the throat, and during respiratory therapy). Evidence suggests that it may be a more common mode for Legionella dissemination than previously believed although it has not been widely described in the literature.<blockquote>

'''REMEMBER!'''

Never presume that you cannot get Legionnaires’ disease

from drinking water containing Legionella.</blockquote>

|}
[[File:Influence of temperature on Legionella growth (Freije 1996).png|alt=Influence of temperature on Legionella growth|none|thumb|604x604px|Influence of temperature on Legionella growth <ref name=":0" />]]

====='''INFECTION AND HOST SUSCEPTIBILITY'''=====
Infections caused by Legionella species are collectively known as ''legionellosis'' and include Legionnaires’ disease and Pontiac fever. Subclinical (asymptomatic) infections have been reported. Legionellosis occurs worldwide, in people of all ages and race groups, with no evidence of person-to-person spread of infection. It is most common in summer and autumn months. The incidence of legionellosis varies from country to country and from region to region. Recently, an increase in the worldwide incidence of reported legionellosis cases has become evident. This may be explained by the availability of improved diagnostic and testing methods, increased awareness of the symptoms and improved surveillance. However legionellosis, especially sporadic cases, is still not always reported to public health authorities, making it difficult to estimate its true incidence.

The mode of transmission, inoculum size, particle size and host susceptibility influence the severity of infection. Approximately half of the currently known Legionella species are implicated in disease, but ''pneumophila'' is still considered to be the causative agent in about 80% of diagnosed cases. However, this picture might change as the number of available diagnostic tests increases – it is thus important to regard all legionellae a potentially pathogenic until proven otherwise.

== Section 3 ==
 

=== LEGIONELLA INFECTIONS ===
Infections caused by Legionella species are collectively known as legionellosis and include Legionnaires’ disease and Pontiac fever.1,2 Subclinical infections have been reported. Legionella infections occur worldwide in people of all ages and race groups with no evidence of person-to-person spread of infection.3,4
 

=== LEGIONNAIRES’ DISEASE ===
Legionnaires’ disease (LD) is a severe multisystem disease with pneumonia as the most predominant clinical finding. Clinical features are similar to those of other pneumonias, making it difficult to diagnose.5,6 Symptoms range from a mild cough and slight fever to a coma with widespread pulmonary infiltrates and multisystem failure. Survivors usually recover completely although lung fibrosis and neurological abnormalities may persist in some cases. LD has a low attack rate but the mortality rate is high.

Legionnaires’ disease outbreaks occur frequently all over the world. In the United States, Legionnaires’ disease is considered to be fairly common and legionellae are among the top three causes of sporadic, community-acquired pneumonia. However, many cases are still not reported, as Legionnaires’ disease is difficult to distinguish from other forms of pneumonia. Although only approximately 1,000 cases are reported to the Centers for Disease Control and Prevention (CDC), it is estimated that over 25,000 cases occur every year, causing more than 4,000 deaths.

Despite this, only one outbreak has been reported in South Africa to date. However, previous South African studies indicated antibody levels to L pneumophila in 65% of healthy blood donors, 36% of healthy mineworkers, 10% of healthy factory workers and 16% of hospitalised pneumonia patients.7,8 One study reported seroconverion to L.

pneumophila in 9% of patients hospitalised between 1987 and 1988 with symptoms of community-acquired pneumonia.9

Figure 3.1 Legionella pathology

=== 3.1 RISK FACTORS ===
In order for LD to occur, the host must be susceptible to infection. Older people (above 50 years of age) are more commonly infected. Men are more likely to be infected (ratio 3:1) but the racial distribution is usually consistent with that of the population involved.10 Table 3.1 lists the most common risk factors.

Table 3.1 Risk factors for development of Legionnaires’ disease

Patient demographics Smoking Chronic pulmonary disease Immunosuppression Renal transplantation Renal dialysis Alcohol ingestion Age > 50 years Male

Environmental risks Exposure to construction activities Exposure to air conditioning systems Exposure to home air conditioning Travelling and accommodation in hotels Potable water Hospitalization

Source: Winn 1984 10

=== 3.2 SYMPTOMS ===
Legionnaires’ disease presents with a broad spectrum of symptoms, ranging from mild cough and low fever to stupor, respiratory and multi organ failure. Pneumonia is the predominant clinical finding. Early symptoms are mainly non-specific and include fever, malaise, myalgias, anorexia and headache.6,11 The temperature often exceeds 40°C and the patient may present with a slightly productive cough. Chest pain, occasionally pleuritic, can be prominent and when coupled with hemoptysis, may mistakenly suggest pulmonary emboli. Gastrointestinal symptoms (watery stools) are prominent, especially diarrhoea, which occurs in 20-40% of cases. Relative bradycardia has been over-

emphasised as a diagnostic finding but is often seen in elderly patients with advanced pneumonia. Hyponatremia (serum sodium concentration ≥ 130 mmol/l) occurs more frequently in Legionnaires’ disease than in other pneumonias.

Extrapulmonary Legionnaires’ disease is rare but the clinical manifestations are often dramatic. These infections can easily be overlooked since the degree of suspicion is generally low in these cases. Legionella has been implicated in cases of sinusitis, cellulitis, pancreatitis, peritonitis and pyelonephritis. The most common extrapulmonary site of infection is the heart. There have been numerous reports of myocarditis, pericarditis, postcardiotomy syndrome and prosthetic valve endocarditis. In most cases there is no pneumonia symptoms present. Wound infections have also been reported.11

=== 3.3 INCUBATION PERIOD ===
LD has an incubation period (the time it takes for symptoms to appear after exposure) of 2 – 10 days. The onset of symptoms may be sudden or gradual.

=== 3.4 DIAGNOSIS ===
There are no reliable distinguishing clinical features to distinguish LD from pneumonia caused by other etiologic agents. However, there are some clinical clues to assist in the diagnosis (Table 3.2).6

Table 3.2 Clinical clues to Legionnaires’ disease

CLUE EXAMPLE

PATIENT HISTORY AND PHYSICAL EXAMINATION

Presence of an epidemic or documented source of

infection

Family, friends or associates with similar infection and exposure

Prominent neurologic or gastrointestinal symptoms

Pneumonia with confusion, nausea and vomiting

Non-response to aminoglycosides or beta-lactam

antibiotics

Worsening condition after 5 days on antibiotics

LABORATORY RESULTS OF PATIENT

Gram stain of sputum with many neutrophils but no

bacteria

Laboratory reports showing many neutrophils and few normal flora or no bacteria

Nodular peripheral infiltrates in chest radiographs Progression of unilateral opacities to bilateral nodular infiltrates over several days

It is important to remember that a clinical diagnosis of LD always has to be confirmed with specialised laboratory tests. As not all laboratories are equipped to perform these tests routinely, the tests have to be specifically requested by the physician. Table 3.3 highlights some of the most commonly used laboratory tests.12

· Culture of Legionella organisms from clinical samples is still the gold standard for diagnosing LD. The technique is highly specific, provided appropirate samples are used, and about 1.5 to 3 times more sensitive than immunofluorescence. Transtracheal aspirates are best for culture, but sputum, bronchial aspirates, pleural exudates, lung biopsies as well as wound swabs and even autopsy material have been used successfully.11 Disadvantages of the culturing of legionellae for diagnostic purposes include possible inhibition by non-legionellae organisms present in the sample, slow growth and difficulties in distinguishing legionellae from other organisms on solid media. These factors must be taken into account when choosing a laboratory to test clinical samples for LD.

· Immunofluorescence is useful to detect antigens (direct immunofluorescence) or antibodies (indirect immunofluorescence) in clinical samples in cases where culture is not possible. Cross reactions with organisms other than Legionella in the direct immunofluorescence (DFA) test may cause false positive results, making accurate

interpretation of the results essential.11,13 Indirect immunofluorescence (IFA) is the most specific of the currently available serological tests for LD. It is reproducible, sensitive and specific for the diagnosis of especially L. pneumophila infections, but may be affected by several factors, including the method of antigen preparation, method of antigen fixation during preparation of the reagent, the class of immunoglobulin it is designed to detect and strain differences.14,15

· The Legionella Urinary Antigen test5 is a relatively inexpensive and rapid diagnostic test, but only detects infections caused by L pneumophila Serogroup 1. The test is commercially available as a radioimmunoassay (RIA) or an enzyme linked immunosorbent assay (ELISA). An advantage of this test is the relative ease with which urine samples can be obtained, especially in patients with a non-productive cough. Legionella antigens may persist in the urine of some patients for as long as one year.

· Serological tests are useful for epidemiologic studies but less valuable for physicians. Diagnosis by serology is based on a fourfold rise in antibody titre to ≥ 1:128 in paired samples (from the acute and convalescent stage of disease).13,15 However, the antibody response may not be detectable until 1-3 months after onset of illness. Single titres of ≥1:256 during convalescence in pneumonia patients is suggestive of legionellosis. Antibody screening should include both IgG and IgM because some patients may only have an IgM response.5

· Assays based on the polymerase chain reaction (PCR) have been used to detect legionellae in urine, broncho-alveolar lavage fluid and sputum. These tests are highly specific but not more sensitive than culture and are much more expensive to perform. Limitations of PCR tests include the possible presence of certain “PCR inhibitors” in sputum and blood samples. The major advantage of PCR is the rapidity of the test and the ability to detect species other than L pneumophila. PCR is not used routinely for the clinical diagnosis of LD.

Table 3.3 Sensitivity and specificity of laboratory tests for the diagnosis of Legionnaires’ disease

TEST SENSITIVITY (%) SPECIFICITY (%)

Culture from clinical samples 80 100

Direct immunofluorescence (DFA) 33-70 96-99

Indirect immunofluorescence (IFA) 40-60 96-99

Urinary antigen detection 70 100

Source: Stout and Yu, 1997

=== 3.5 HISTOLOGY ===
Pulmonary lesions usually consist of a mixture of neutrophils and macrophages, fibrin, proteinaceous material and red blood cells. Neutrophils and macrophages are often present in the centre of a lesion with mainly macrophages around the periphery.

Intracellular bacteria are present in both neutrophils and macrophages. Further away from the site of acute inflammation, bacteria are mainly seen inside the macrophages.10

Figure 3.3 Histological section of lung of Legionnaires disease patient

=== 3.6 CHEST RADIOGRAPHS ===
Radiographic features in Legionnaires’ disease are mostly non-specific, and absent in Pontiac fever. Abnormalities occur from the third day post infection in most Legionnaires’ disease patients and usually do not correlate well with the severity of illness.11 However, the abnormalities correlate with the presence of the Legionella bacterium in sputum. The time required to show clearing of infiltrates on radiographs is variable and may range from 1-4 months. Some patients show diffuse alveolar damage. In the majority of patients with Legionnaires’ disease:

· Initial involvement is unilateral, predominantly in the lower lobe

· Bilateral involvement has been described

· Initial densities are poorly marginated, homogenous, rounded, occur either on the periphery or in the centre of the lung and may be mistaken for pulmonary infarction

· Pulmonary densities enlarge during later stages of disease

· Pulmonary densities have a typical ground glass appearance or dense consolidation

· Total opacification of the lung may occur

· Pleural effusions are present in 24-63% of cases caused by L pneumophila

· Pleural effusions are uncommon in L micdadei infections

· Hilar adenopathy seldom occurs

· Cavitation may occur in immunocompromised patients

· Cavitation rarely occurs in L micdadei infections

Figure 3.4 Chest radiograph of Legionnaires’ disease patient

=== 3.7 TREATMENT ===
Treatment of LD requires the use of antibiotics. However, many antibiotics effective against other bacterial pneumonias are ineffective against Legionella as these drugs do not penetrate the pulmonary cells (alveolar macrophages) where infectious Legionella bacteria thrive.

Erythromycin was historically the drug of choice for the treatment of Legionnaires’ disease, but the newer macrolides (azithromycin) and quinolones (ciprofloxacin, levofloxacin, moxifloxacin, gemifloxacin, trovofloxacin have superior in vitro activity and greater intracellular and lung-tissue penetration.12 Other agents that have been shown to be effective include tetracycline, doxycycline, minocycline, trimethoprim- sulfamethoxazole.12 Rifampin is recommended as part of combination therapy with a macrolide or a quinolone for patients who are severely ill. The total duration of therapy is usually 10-14 days; however a 21-day course may be needed for immuno-compromised patients or those with extensive evidence of disease on chest radiographs.12

When LD patients are treated with appropriate antibiotics near the onset of disease, the prognosis is usually very good, especially if there is no underlying illness compromising the immune system. For patients with compromised immune systems, including transplant patients, any delay of appropriate treatment may result in complications, prolonged hospitalisation and death. However after successful treatment and hospital discharge, many patients still experience fatigue, loss of energy and difficulty concentrating. These symptoms may persist for several months, but complete recovery usually occurs within one year.

=== PONTIAC FEVER ===
Pontiac fever is an acute, self-limiting, flu-like illness without symptoms of pneumonia. The first outbreak of Pontiac fever was reported in Pontiac, Michigan, in 1968.16

It is characterised by high fever, chills, myalgia and malaise but without the pneumonia or cough typical of Legionnaires’ disease. Some authors suggest that it is a hypersensitivity pneumonitis, caused either by infection with a free-living amoeba called Acanthamoeba filled with legionellae or as a result of a toxic reaction to the organism. The incubation period is short, ranging from 1 – 3 days, and the attack rate high, exceeding 90% in some cases. The fatality rate is low.

Pontiac fever symptoms usually resolve spontaneously within one week, only symptomatic treatment is needed and the chest radiograph is clear. There is no evidence of secondary spread of the infection in Pontiac fever. Diagnosis can only be made by seroconversion, which may be delayed for up to 6 weeks after onset of symptoms. Cases of PF have been linked to L pneumophila, L feelei and L anisa. Complete recovery usually occurs in 2 – 5 days without medical attention

==References==
<references />
[[Category:Legionella Control]]
[[Category:Infection Prevention and Control]]
[[Category:Water Distributions Systems]]

Infrastructure Unit System Support

2020-09-25T10:06:17Z

Tmojanaga: /* Additional Supporting Documents */

=='''About [http://www.iussonline.co.za IUSS]'''==
This IUSS Online website is the repository for documents and tools developed under the Infrastructure Unit System Support - IUSS - project, an initiative of the National Department of Health, under the leadership of Dr Massoud Shaker and Mr Ndinannyi Mphaphuli. The purpose of the documents is to provide guidance and improved healthcare infrastructure delivery.

==Document List==
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|'''SUPPORT SERVICES'''
|'''HEALTHCARE ENVIRONMENT/ CROSSCUTTING ISSUES'''
|'''PROCUREMENT'''

'''& OPERATION'''
|-
|In-patient services
|[https://www.iussonline.co.za/docman/document/support-services/115-admin-and-related-services-gazetted/file Administration & Related Services]
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|-
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|[https://www.iussonline.co.za/docman/document/clinical-services/71-mental-health-gazetted/file Mental Health]
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|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file Building Engineering Services]
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|-
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|[https://www.iussonline.co.za/docman/document/support-services/96-health-facility-residential-gazetted/file Health Facility Residential]
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|[https://www.iussonline.co.za/docman/document/procurement-and-operation/88-maintenance-gazetted/file Maintenance]
|-
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|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/79-inclusive-environments-gazetted/file Inclusive Environments]
|[https://www.iussonline.co.za/docman/document/procurement-and-operation/86-decommissioning-gazetted/file Decommissioning of Healthcare Infrastructure and Healthcare Technology]
|-
|[https://www.iussonline.co.za/norms-standards/clinical-services/19-paediatrics-and-neonatal-facilities Paediatrics and Neonatal Facilities]
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|
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|[https://www.iussonline.co.za/docman/document/clinical-services/76-phc-gazetted/file Primary Healthcare Facility]
|
|Regulations
|
|-
|Diagnostic radiology
|
|
|
|-
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|
|
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|-
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|
|
|
|-
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|
|
|
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/77-tb-services-proposal-gazetted/file TB]
|
|
|
|}

==Additional Supporting Documents==
{| class="wikitable"
|'''CLINICAL SERVICES'''
|'''SUPPORT SERVICES'''
|'''HEALTHCARE ENVIRONMENT/ CROSSCUTTING ISSUES'''
|'''PROCUREMENT'''

'''& OPERATION'''
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/64-adult-critical-care-gazetted/file Adult Critical Care]
|[https://www.iussonline.co.za/docman/document/support-services/94-central-sterile-service-department-gazetted/file Central Sterile Service Department]
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/87-ibts-for-phc-gazetted/file Building Clinic Facilities with Innovative Building Technologies]
|Detail Estimator for a New Hospital
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/65-adult-inpatent-services-gazetted/file Adult Inpatient Services]
|General hospital support services
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/111-aap-functional-space-neonatal-140425-rev-01/file Generic Room Requirements - Functional space: Neonatal]
|[https://www.iussonline.co.za/docman/document/procurement-and-operation/92-fast-user-manual-gazetted/file Detail Estimator for a New Hospital]
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/66-adult-oncology-gazetted/file Adult Oncology Facilities]
|[https://www.iussonline.co.za/docman/document/support-services/96-health-facility-residential-gazetted/file Health Facility Residential]
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/113-ajhc-neonatal-baby-resus-140425-rev-01/file Generic Room Requirements - Functional Space: Neonatal Baby Resuscitation]
|[https://www.iussonline.co.za/docman/document/procurement-and-operation/109-2014-08-26-iuss-briefing-manual-gazetted/file IUSS Health Facility Guides: Briefing Manual]
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/67-adult-physical-rehabilitation-gazetted/file Adult Physical Rehabilitation]
|[https://www.iussonline.co.za/norms-standards/support-services/28-hospital-design-principles-2 Hospital Design Principles]
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/110-an-functional-space-theatre-140425-rev-01/file Generic Room Requirements - Functional space: Pre Op]
|[https://www.iussonline.co.za/norms-standards/procurement-and-operation/81-maximum-usable-space-design-musd-estimator Maximum Usable Space Design (MUSD) Estimator (Ungazetted)]
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/68-clinical-and-specialised-diagnostic-laboratories-gazetted/file Clinical and Specialised Diagnostic Laboratories]
|[https://www.iussonline.co.za/docman/document/support-services/98-hospital-mortuary-services-gazetted/file Hospital Mortuary Services]
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/114-ak-procedure-room-140425-rev-01/file Generic Room Requirements - Functional space: Procedure Room]
|OoM Estimator for New Clinic Community Day Centre or Community Health Centre
|-
|[https://www.iussonline.co.za/norms-standards/clinical-services/14-facilities-for-surgical-procedures Facilities for Surgical Procedures]
|[https://www.iussonline.co.za/norms-standards/support-services/61-infrastructure-design-for-waste-management-in-healthcare-facilities Infrastructure Design for Waste Management in Healthcare Facilities]
|[https://www.iussonline.co.za/norms-standards/healthcare-environment/48-generic-room-requirements-functional-space-treatment-room Generic Room Requirements - Functional space: Treatment Room]
|OoM Estimator for New Hospitals
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/70-maternity-care-facilities-proposal-gazetted/file Maternity Care Facilities]
|[https://www.iussonline.co.za/docman/document/support-services/100-nursing-colleges-and-student-accommodation-gazetted/file Nursing Education Institutions]
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/112-aja-treatment-room-140425-rev-01/file Generic Room Requirements - Functional space: Treatment Room]
|OoM Estimator for Upgrade or Additions to Clinic, Community Day Centre or Community Health Centre
|-
|
|
|[https://www.iussonline.co.za/docman/ungazetted-documents/healthcare-environment-crosscutting-issues-1/126-iuss-healthcare-technology-proposal/file Healthcare Technology Proposal (Ungazetted)]
|OoM Estimator: Upgrade/Additions to Hospitals
|-
|
|
|
|OoM Maintenance Estimator for Clinic. CDC and CHC
|-
|
|
|
|OoM Maintenance Estimator for Hospitals
|-
|
|
|
|[https://www.iussonline.co.za/docman/document/procurement-and-operation/89-space-guidelines-qs-architect-instruction-gazetted/file Space Guidelines QS Architect Instruction]
|}

==Application==
IUSS voluntary standard/ guidance documents have been prepared as national Guidelines, Norms and Standards for the benefit of all South Africans. They are for use by those involved in the procurement, design, management and commissioning of public healthcare infrastructure. Many have been made mandatory via gazette and are clearly marked with this status on the front cover and in footers on each page. IUSS material may also be useful information and reference to private sector healthcare providers.

Use of the guidance does not absolve professional responsibilities of the implementing parties, and it remains incumbent on the relevant authorities and professionals to ensure that these are applied with due diligence, and where appropriate, deviations processes are exercised.

Gazetted guidelines are for public reference information and for application by Provincial Departments of Health in the planning and implementation of public sector health facilities. The gazetted guidelines will be applicable to the planning, design and implementation of all new public-sector building projects (including additions and alterations to existing facilities). Any deviations from the voluntary standards are to be motivated during the Infrastructure Delivery Management Systems (IDMS) gateway approval process. The guidelines should not be seen as necessitating the alteration and upgrading of any existing healthcare facilities.

==Development process==
The development process initiated in 2010 was to consolidate information from a range of sources including local and international literature, expert opinion, practice and expert group workshop into a first-level discussion status document. This was then released for public comment through the project website, as well as national and provincial channels. Feedback and further development were consolidated into a second-level development status document which again was released for comment and rigorous technical review. Further feedback was incorporated into proposal status documents and formally submitted to the National Department of Health. Once signed off, the documents were gazetted.

Documents and tools have been assigned a version number and date. The National Department of Health will establish a Health Infrastructure Norms Advisory Committee, which will be responsible for the periodic review and formal update of documents and tools. Documents and tools should therefore always be retrieved from the website repository www.iussonline.co.za or Department web portal (forthcoming) to ensure that the latest version is being used.

Updating is currently limited to quarterly cost models updates only. Feedback is welcome and updates will be posted if these become available.

==Acknowledgements==

IUSS Norms and Standards were developed with extensive input from numerous individuals and the contributions are appreciated and noted in individual publications.
<gallery>
File:CSIR logo.jpg|Council for Scientific and Industrial Research
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[[Category:IUSS]]

Infrastructure Unit System Support

2020-09-25T09:53:47Z