Ebola Building Standards

The Fourth Draft of the Elements of a Model Building Standard or Model Building Protocols for the Construction of Ebola and Contagious Disease Healthcare Facilities In Developing Nations

Background and Introduction

A small pro-bono coalition comprising a New Zealand lawyer from Australia, a building controller from New Zealand, both senior office bearers in the New Zealand Institute of Building have teamed up with a coalition of international experts that has grown organically, to prepare draft elements for model building standards that can be used in the construction of Ebola and contagious disease healthcare facilities in developing nations such as Liberia, Mali and Sierra Leone. The draft instrument is exactly that, a ‘draft’ and the instrument will continue to be a work in progress as further critical input is adopted and embraced to assist with the honing of the instrument.[1]

It is our ultimate hope that once fully evolved the instrument could be utilized by regulators in the shaping of policy discussions and analysis that will ultimately find their way into the proclamation of building regulations that allow for the construction of such health care facilities.

The Ebola epidemic’s epicentre is West Africa and is afflicting Guinea, Sierra Leone, Nigeria, Senegal and Liberia and the first case of Ebola being transmitted in Europe was recorded on the 6th of October where a nurse contracted Ebola after having cared for a Spanish priest who had returned with the condition from West Africa. Ebola is an exceptionally pernicious disease and highly contagious. It is also known as Ebola Haemorrhagic Fever as it causes major internal organ haemorrhaging.

The first manifestation of Ebola occurred in Zaire in 1976[2], now called the Democratic Republic of Congo (DRC) near the Ebola River and there have been spasmodic breakouts of Ebola in the last four decades. The current epidemic induced deaths well exceed the aggregate number of Ebola deaths since 1976. No previous outbreak ever killed more than 280 people. In the past the Ebola outbreaks have tended to be in the more remote regions of parts of Africa such as the Democratic Republic of Congo, but this epidemic is proliferating at an alarming rate in major West African metropolises like Monrovia and Freetown. Because of the high concentration of people living in congested, intimate and destitute conditions, the opportunity for exponential proliferation is much greater.

The disease is spreading aggressively in Sierra Leone, Guinea, Liberia and Mali and has assumed the status of a world health emergency, in light of its potential to kill hundreds of thousands of people in Africa and to spread to other countries unless arrested. Dr. Margaret Chan, the Director-General of WHO on the 18th of September addressed an emergency session to the UN Security Council concerning Ebola[3], stating “This virus, this deadly and dreaded Ebola virus, got ahead of us in a fast-moving outbreak…This is likely the greatest peacetime challenge that the United Nations and its agencies have ever faced….None of us experienced in containing outbreaks has ever seen, in our lifetimes, an emergency on this scale, with this degree of suffering, and with this magnitude of cascading consequences….This is not just an outbreak. This is not just a public health crisis. This is a social crisis, a humanitarian crisis, an economic crisis, and a threat to national security well beyond the outbreak zones”.

At a press conference[4] on Tuesday, 2nd of September, Dr. Tom Frieden the director of Centers for Disease Control and Prevent (CDC) stated “This isn’t just the countries’ problem, it’s a global problem.”…“The level of outbreak is beyond anything we’ve seen—or even imagined,”….“For every day that this continues to spread in West Africa, the likelihood of someone getting infected and transmitting it elsewhere increases,”…“As long as Ebola is spreading anywhere, all of us need to be concerned.”

On the 2nd of October, Mr. Anthony Banbury, the Head of the UN Mission for Ebola Emergency Response (UNMEER) spoke to reporters in Monrovia, Liberia stating “The objective of UNMEER is very easy: to contribute to the international and national efforts to stop Ebola, to end this crisis, to save lives. That’s what we’re here for,”…. “The only way we will end this crisis is if we end every last case of Ebola so there is no more risk of transmission to anyone…”[5]

How is the Disease Transmitted?

In some parts of West Africa there is a propensity on the part of some to eat “bushmeat” which can be primate or fruit bat meat and Ebola can be transmitted to human beings via eating, preparing, processing, cooking, or handling these mammals. Nevertheless Mr. Leonard Peruski Director of Global Disease Detection – Central America, US Centers for Disease Control and Prevention, when commenting on this draft standard stated that “Since the first recorded Ebola outbreak in 1976 there have been only 30 single “spillover events” from animals into humans”[1] It will therefore follow that there is some contentiousness about the correlation between bushmeat and Ebola migration to humans.

Transmission may also occur by exposure or close proximity to the areas in which these activities occur. The disease is spread through bodily fluid mediums and agents such as perspiration, saliva, blood, urine, faeces and the handling of people harbouring the infection regardless of whether they are dead or alive. Sometimes called the “caregiver’s disease”, the term was coined by virtue of the fact that Ebola proliferates quickly amongst family members because it is counterintuitive for them not to hold or maintain close contact with siblings, children or parents afflicted with the condition.

Ebola has an incubation period of between 2 and 21 days with the average being 8 to 10 days. The corpses of Ebola victims remain highly contagious for many weeks after death.

Although unlikely, it is not inconceivable that if the disease is not halted the rapid mutation capabilities of the disease could in a worst case scenario generate an airborne strain. “Much media speculation has arisen over the possibility of the disease mutating into an airborne variant. The most effective way to prevent this from occurring is the prompt eradication of this outbreak while the virus remains incapable of doing so. The virus is easily aerosolized in the fine particulate matter ejected from a patient’s coughing. This is a form of direct transmission and is a completely different vector than airborne transmission”.[6]

In developing countries particularly, in areas where there is a high concentration of people with the complement of poor sanitary and intimate living conditions Ebola can proliferate with alarming alacrity. The 2014 outbreaks represents a paradigm shift. Whereas in the past, the concentration of Ebola outbreaks was in remote regions of the Democratic Republic of Congo, the difference with this epidemic is that the highest concentration levels are in West African metropolises.

There is an emerging opinion that the gravitation of the disease to urban areas emanates from the deforestation that is occurring in some parts of Africa like the Congo. Areas that have recently experienced significant tree and fauna destruction have been traditional abodes for particularly virulent and pernicious diseases that can migrate with natural hosts such as fruit bats. Some of these animals are on the move and have provided vehicles for contagious disease migration.

Statistics regarding numbers of deaths and countries affected

[7]

Statistics as at 5 ^th of October 2014	Statistics as at 20 ^th of November 2014	Statistics as at 3 ^th December 2014 [8]
Liberia Cases: 3,924 Deaths: 2,210	Liberia Cases: 7,069 Deaths: 2,964	Liberia Cases: 7,635 Deaths: 3,145
Guinea Cases: 1,298 Deaths: 768	Guinea Cases: 1,971 Deaths: 1,192	Guinea Cases: 2,164 Deaths: 1.327
Sierra Leone Cases:2,789 Deaths: 879	Sierra Leone Cases: 6,073 Deaths:1,250	Sierra Leone Cases: 7,312 Deaths: 1,583
DRC Cases: 66 Deaths: 43	DRC Cases: 66 Deaths: 49	DRC Data Unavailable
Nigeria Cases: 20 Deaths: 8	Nigeria Cases: 20 Deaths: 8	Nigeria Cases: 20 Deaths: 8
United States Cases: 4 Deaths:1	United States Cases: 4 Deaths:1	United States Cases: 4 Deaths:1
Spain Cases: 3 Deaths:2	Spain Cases: 3 Deaths:2	Outbreak Declared Over
	Mali Cases: 6 Deaths: 5	Mali Cases: 6 Deaths:5
	Senegal Cases: 1 Deaths: 0	Senegal Cases: 1 Deaths: 0

Total Recorded Deaths: 3,482 (5th October)

Total Recorded Deaths: 3,865 (10th October)

Total Recorded Deaths: 5,420 (20th November)

Total Recorded Deaths: 6,070 (3rd December)

There is widespread speculation that the number of cases well exceed the number of cases officially identified, particularly in West Africa where the statistics could be a massive underestimate.

Trending Implications:

An MMWR report released on the 14th of November stated that “A reduction in cases suggests some progress; however eliminating Ebola transmission is the critical goal and will require greatly intensified efforts for complete, high quality surveillance to direct and drive the rapid intervention, tracking and response efforts that remain essential” [9].

Dr Dirk Brockmann of Humboldt University in Berlin, and Dr Dirk Helbing of the Federal Institute of Technology in Zurich, have created a computer model that calculates how a virus may spread geographically, stating that London’s Gatwick and Heathrow airports face a greater risk at a combined 8.5 percent, followed by Brussels. Germany, with its main international airport at Frankfurt, has a lower risk than England and France. The probability that an Ebola patient can reach another African country, such as Ghana, is higher[10].

Symptomology

An Ebola sufferer will encounter a range of symptoms including but not limited to:

Diarrhoea
Fevers
Coughing
Severe joint pain
Extreme headaches
Severe debilitation
Internal haemorrhaging
Bleeding from orifices

Dr. Bruce Aylward, Assistant Director-General WHO has recently stated that the current mortality rate in the 2014 outbreak is running at 70% and it appears that the mortality rates can be influenced to some degree by the level and sophistication of healthcare facilities and the availability of healthcare workers that can be deployed in a timely fashion. There is currently no cure for Ebola although some test drugs such as ZMapp harbour promise.

There is an acute shortage of Ebola healthcare facilities and healthcare workers in West Africa and the international community has mobilised to pledge resources to this part of the world. The resource mobilisation consists of the pledging of large sums of money, the provision of healthcare workers (for instance Cuba has pledged 160 healthcare workers), military support and the acceleration of research aimed at finding cures for Ebola.

The United States will spend $100 million to fight the outbreak of Ebola and send up to 4,000 military and health personnel to West Africa.[11]

The UK has provided over £200 million (US$313 million) in response to the Ebola outbreak and the Prime Minister has secured funding of £800 million or €1 billion (US $1.25 billion) at the European Council Meeting for a global effort to contain the disease as well as sending British troops and health workers[12].

China has pledged 750 million yuan (US $123 million) to the fight against the Ebola epidemic as well as sending 1,000 personnel to fight the Ebola epidemic[13].

The Merits in Developing Building Regulations that Adopt Model Standards & Relevant CDC Guidelines

It is paramount that in formulating standards that can be called up in building regulations regard is had to the “international epicentres of expertise”, such as the Centers for Disease Control and Prevention (CDC) and WHO. This document aims to identify some key elements that could find their way into Ebola protocols, which must nevertheless be subordinate to prescriptive protocols that have been published by institutions like the CDC and WHO.
One of the authors[18] of this document has a background in building regulatory law reform and legislative development and is of the view that law makers in Ebola afflicted countries could consider generating new building regulations that specifically deal with construction protocols and methodologies for the erection of Ebola healthcare facilities. Absent uniform regulations that are promulgated by acts of parliament, there could be considerable variation or deviation from best practice international guidelines. Furthermore, if best practice standards find their way into codified building regulations, it is easier for regulators and law enforcers to ensure that the healthcare facilities are built in a manner that has regard to adequate safety holistics.

The Healthcare Facility Construction Standard Imperative

Mindful of the inadequate and humble healthcare infrastructure in many parts of the developing World such as West Africa, there is a desperate need to build facilities for the treatment of Ebola sufferers. Such facilities will conceivably have unique construction, occupational, health, safety and “facility-in-operation” facets that are sensitive to the peculiarities of Ebola disease transmission. It is critical that construction method and materials have regard to CDC operational requirements for Ebola healthcare facilities.

There is a need for a set of regulatory elements or protocols that can either find their way into model regulations or an international standard to assist designers, builders, and facility managers with the construction, maintenance and use of Ebola healthcare facilities. This paper and these model elements are currently being evolved and will be a work in progress as expert commentary input is sought and as the drafts evolve.

Ideally the standard will provide food for thought for policy makers tasked with the obligation of not only remedying the current situation but also developing sustainable long term solutions for health infrastructure in the developing world.

The Centers for Disease Control and Prevention (CDC) have published a very comprehensive and rigorous prescriptive guideline with respect to the use and operation of Ebola healthcare facilities. These guidelines can be accessed by logging into the CDC’s Ebola Virus Disease website. In terms of protocols and intricate procedures and guidelines with regards to the use of healthcare facilities, the procedures and protocols enunciated in the CDC’s guidelines will take precedence over any of the provisions in this draft standard. Log in to the CDC website to view the guidelines at www.cdc.gov [14].

The CDC has also provided “Interim Guidance for Specimen Collection, Transport, Testing, and Submission for Persons under Investigation for Ebola Virus Disease in the United States”. The guidelines can be accessed by logging into http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-specimen-collection-submission-patients-suspected-infection-ebola.html[15].

As Ebola continues to proliferate, law makers should give consideration to promulgating parliamentary sanctioned building regulations that have regard to some of the considerations that are identified in this paper, but more importantly, take cognisance of CDC Ebola protocols that should influence the construction methodology, design and materials used for the construction of Ebola healthcare facilities.

In Africa in particular, new facilities will need to be built to deal with the epidemic and legislators could consider promulgating regulations that allow for rapid construction outcomes, but by the same token are sensitive to best practice contagion containment and patient recovery considerations.

“Facilities would ideally be built with the view of developing a long term sustainable contribution to health systems in these regions. In taking into consideration contextual factors it must be said that Ebola is not the only health concern afflicting developing communities. Implementation of short term solutions fail to take these factors into account. Taking a short term approach to the Ebola containment has the inherent shortfall of not being able to cope with any future outbreaks of Ebola or other contagious diseases. One such example is Lassa Fever which kills approximately 5,000 people annually and accounts for 10%-16% of hospital admissions in Liberia[16].

If the current Ebola outbreak is quelled only to be substituted by another contagious disease to some extent the efforts of those on the frontline and the international community will be have been compromised. Creating permanent facilities has the potential to create a legacy out of the Ebola tragedy that there is long term health care capability.”[17]

The Objectives of the Elements for the Standard

Ebola and Contagious Disease healthcare facilities must be constructed in a manner that optimises the opportunity for care and recovery of Ebola and Contagious Disease patients.
Ebola healthcare facilities must be constructed in a manner that optimises the safety of healthcare workers or any other individuals that visit, work in or provide assistance to Ebola sufferers.
Ebola healthcare facilities must be constructed in a manner that quarantines the sufferers to ensure that the contagion is contained within the particular facility and cannot be spread through any means of egress or human or animal transmission.
The designs and construction methodologies for building Ebola healthcare facilities must be able to be such that the facilities can be built quickly, cost effectively and in a manner that is if at all possible sensitive to environmental sustainability.
The standards must have regard to developing protocols and procedures published for the Centers for Disease Control and Prevention (CDC).
The structures will preferably be of a permanent nature so that they may be used in the future for any further outbreaks of Ebola or other contagious diseases. Permanent facilities will help serve economically challenged communities by providing a means of long term sustainable health care infrastructure that can be used for a variety of purposes.
The Standards are designed specifically for regions where there is a high concentration of financially challenged people living in overcrowded regions and abodes and encumbered with very poor health infrastructure. Countries such as Guinea, Sierra Leone, Senegal and Liberia exhibit characteristics of this paradigm and have environments that are conducive to the proliferation of contagious diseases. Challenging geopolitical and religio-cultural considerations must also be taken into account when drafting standards.

Key Elements for a Model Standard

The Key Elements for a Model Standard are outlined in Figure 1, and described further in table 1. The basic primary elements are:

1. Design

Design needs to cater for the unique internal environment simultaneously managing the balance with the external environment. Space management is essential to plan in advance and needs to work with how material, people and equipment articulate through the facilities. Importantly, finishes are needed that enable the control of pathogenic spread and maintaining a clinically clean environment.

2. Function

There are several functions that are needed to be facilitated. These are: disease/patient management, waste management, medical protocols, administration, storage, security, health care workers (HCW) and other staff needs. Stringent security measures and protocols need to be deployed to ensure that harm is not visited upon healthcare workers and patients in the event that people living in fear or harboring misunderstanding become violent. It follows that there has to be access to security personnel.

3. Construction

Building services, materials and construction methods need to acknowledge and support the various functions and simultaneously deal with delivery and context issues not commonly experienced.

4. Delivery of the Facilities

Delivery needs to recognise the rapid response nature and requirements for transportability, scalability, and prefabrication.

5. Context

Unique context issues provide the challenge for which the model building standard exists and it needs to address the other key elements. The standard has been formulated with the view of being applied to developing country paradigms in West Africa.

6. Long Term Healthcare Facility Capacity Building

Design of the facilities should also be sensitive to the fact that the facilities may be used after the Ebola epidemic is arrested as longer term healthcare facilities to build up health infrastructure.

7. Although at this time Ebola cannot be spread through the air, regard must be had to the fact that in a healthcare facility there will be a higher than normal concentration of airborne droplets thus increasing the potential for disease migration within the facility. Hence regard must be had to ventilation systems that can expel or trap respiratory emissions without posing any threat to uninfected third parties or healthcare workers.

Maintenance Manuals

Healthcare facilitates must at all times be maintained in a manner that maximises the opportunity for Ebola patients’ recovery and the health and safety of healthcare workers.
Healthcare facilities and patient handling procedures must be managed with the highest level of vigilance. Note that the first case of contraction of Ebola in Europe has occurred in a Spanish containment centre in a hospital. The nurse in question was wearing a protective suit and only attended to the Ebola patient on two separate occasions, yet still managed to contract Ebola.
All healthcare workers must be trained and inducted in CDC Ebola healthcare protocols prior to their work being sanctioned. It follows that trained professionals with skills and experience in contagious disease containment need to train inductees.

Figure 1: Key Elements of the Ebola Model Building

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Table 1: Key Element Requirements

Key Element		Requirements

1.1.Design
	1.1.1 Environment	Internal environment: Minimizes the risk of being infected by Ebola to “0” or as close as possible to “0”. Allows for frequent daily sanitization and application of disinfectants. Temperature control systems to minimize human perspiration, mindful of the fact that healthcare workers wear protective suits that are conducive to a high level of perspiration particularly in circumstances where there are human resource shortages and intensive and long periods of deployment are required. Temperature control should also be sensitive to the fact that the Ebola virus causes fever and perspiration seeps into bedding and blankets which become saturated with Ebola infested fluids. External Environment: Roof and wall elements should be designed to prevent excessive radiant heat and solar gain, i.e. high insulation values. Where possible allow for balance between internal and external environment to work together in a passive nature.
	1.1.2 Space Management	Spaces created by transportable modules and elements. Scalable for fluctuation in demand. Separate generator and fuel for backup.
	1.1.3 Articulation	Patients are segregated from open areas and are denied access to open areas. Staff only in isolation areas for staff. Staff are able to articulate easily within facilities. Fire egress for evacuation. Clear passage for entry and exit of vehicles. Supplies to be kept a safe distance from infected persons, contaminated clothes, HCW change rooms, decontamination chamber and any other areas that have come into contact with the virus. This includes separated facilities for food, water and necessary materials such as clothing, linen, medicines etc. Fresh water to be kept on site. This should be kept a safe distance from any possible contamination. Facilities should be fenced for security reasons. A chain link fence with barbed wire running along its top is one possible solution as it is cheap, quick and easy to erect and effective. Decontamination rooms for staff and others that have come into contact with infected persons.
	1.1.4 Finishes	Facilities must be designed to minimise the potential for spread of contagion and must be anti-pathogenic.
1.2.Function
	1.2.1 Disease /Patient Management	Patients are able to be segregated, isolated and treated when needed. Ebola suspects ward: The symptoms of Ebola are very similar to other diseases such as malaria. For this reason it may be necessary to have an observation ward where patients are assessed before being exposed to bona fide Ebola patients. Separate wards for ‘more contagious’ patients. A ‘recovery’ ward is preferable for observation of patients prior to being discharged.
	1.2.2 Waste Management	Facilities need to be constructed in a fashion that maximises hygiene and the opportunity for the rapid evacuation of urine, vomit debris and faeces without posing any risk of spread of the disease through these bodily mediums of fluid exchange. For this to occur there would be merit in the incorporation of incineration devices. Critical regard must be taken for the destruction of highly contagious human waste such as faeces and urine. This may be achieved through incineration, so that organic and combustible waste is reduced to inorganic, incombustible matter. Incinerators should be low cost and capable of generating very high temperatures to effectively and economically destroy waste. In Brazil mobile incinerators have been utilized to destroy waste. Onsite incinerators will eliminate the risk of disease migration through transported waste.[19] Incineration devices may also serve the function of cremation of the deceased in circumstances where there is no cultural or familial objection. Wards and decontamination chambers to have slight descending gradient in floor for drainage of fluids/hose water. Adequate means of fluid waste disposal needed as Fluid waste still contains contagions. Note: The writers welcome ideas on how best to eliminate and destroy ‘toxic greywater’ and those with experience in the construction of plumbing components of disease containment facilities would be welcome to comment.
	1.2.3 Medical Protocols	Protocols for management and use of such facilities need to be in accordance with internationally recognized guidelines published by WHO and CDC. The virus eradication must take into account the world’s best practice technology and innovations on Ebola virus liquidation. The use of robots such as ‘Little Moe’,[20] which emit a high powered UV frequency that can destroy the virus warrant consideration. The use of such robots could be utilized in conjunction with conventional cleaning products for highly contagious diseases, to eradicate the virus.
	1.2.4 Administration and Communication	Facilitate information management and accurate records. Communication facilities. Communication devices must be “immune” to power shortage and poor cellular connection. Satellite phone with visual interactive screens is one such possibility if cellular infrastructure is problematic. There is a view that patients who are in possession of mobile phones that enable them to communicate with family members may have a better chance of recovery on account of familial empathy and higher morale. It follows that the ward facilities should provide the communication infrastructure for cellular communication.
	1.2.5 Storage	Hazardous equipment and material storage to ensure that contaminated materials such as sheets, bed linen, retired gloves, clothing, food, eating and cleaning utensils can be compiled and placed in sanctioned bags and boxes for swift dispatch and supervised destruction.
	1.2.6 Security	Staff need to feel secure from both pathogens and any civil unrest. Keying system with CCTV in sensitive areas. Security presence at entrance ensuring safe entry/exit of vehicles and staff. Security patrolling perimeter of the facility if required. Chain link barbed wire fence. Supervised gate opened only where there is sanctioned ingress and egress of personnel and vehicles.
	1.2.7 Staff	Separate staff facilities for: rest, mess and toilets. Separate rooms for HCW to change into their PPE. HCW to change out of their PPE in the decontamination chamber.
	1.2.8 Ventilation/Insulation	Adequate insulation is essential to keep temperature stable.
	1.2.9 Cooling	Due to the climate in West Africa regard must be had to adequate and efficient cooling systems. Due to fever symptoms of Ebola and the protective clothing worn temperature must be kept low to limit perspiration. Potential cooling systems must be cheap, efficient and not need any great deal of expertise to maintain. The quarantine ward and isolation wards need to be separated from one another to access external air currents without obstruction. (See additional commentary on point 21 ) Air vents should be on the high side of the walls well above human body height to minimize risk of contagion to outside persons.
1.3.Construction
	1.3.1 Building Services	Reliance on energy kept to a minimum. Ideally solar energy with a back up generator. Ventilation achieved by passive stack effect is one possibility. Passive Stack information can be found at: http://www.passivent.com/downloads/ip13_94.pdf Small local areas conditioned for cooler requirements.
	1.3.2 Materials	Light and robust. Limited selection of type. Easy to replace. Ideally permanent materials will be used that can have a permanent application so that the facility can serve in the future as regional healthcare facilities. In the event of any future outbreak of Ebola or other highly contagious diseases, the facility may also be used as a regional hospital should it be required. Materials should be such that the structure can be erected without any great level of expertise required. Permanent foundations. Currently there are Ebola treatment facilities that have plastic covered wooden floors. This option is merely short term and lacks the durability to be used as a permanent infectious disease hospital. Interior materials must not be porous as porous material could cause contamination and contagion spread.
	1.3.3 Construction Methods	Need to allow for rapid construction techniques such as prefabrication. Construction methods should take into account that due to the urgency to build treatment facilities the services of persons lacking experience in construction may be called upon. Assembly should be such that unskilled personnel would be able to erect the facilities with appropriate supervision. Structure will ideally be permanent. Locally produced bricks and cement blocks may be a suitable option.
	1.3.4 Power	Solar energy is a viable option to power the facility given the geographical location and the one off expense that has no operational cost. An example of such a facility is the Solar powered hospital in Haiti ‘Hôpital Universitaire de Mirebalais’ which has 300 beds, sees up to 700 outpatients per day and cost around $US20million to build[21].
1.4.Delivery
	1.4.1 Rapid Response	Construction materials and methodologies facilitate construction and deployment of facilities in the swiftest and most cost effective fashion. If possible try to source materials locally or within the region to save on time/bolster local economy. Materials need to be adapted to the local environment and be capable of withstanding harsh conditions.
	1.4.2 Transportable	Modules, equipment and fit-out all selected for transportability.
	1.4.3 Prefabrication	Mass produced in controlled environment and shipped out. Preferably hard shell and permanent to assist with long term health care capability development.
	1.4.4 Scalability	Start with essential modules and add on as needed by scale.
1.5.Context
	1.5.1 Isolation	This means basic facilities may be missing requiring the need for further services on site such as laundry, cooking and sleeping facilities; all of which have the potential to facilitate transmission of diseases, so care must be taken and proper supervision provided.
	1.5.2 Low Tech.	Construction skills may be minimal so this type of facility needs to be sensitive to local skill constraints. Needs to enable easy assembly on site and setup. Utilities and ICT (information communications technology) need to be self-contained and robust. Any spare parts should be easy to locate and generic.
	1.5.3 Civil Distress	Structure and fabric need to be robust, and spaces sealable and lockable.
	1.5.4 Harsh Environment	Supplies for water, fuel and food need to be stored and secured on site.
	1.5.5 Nature of Disease	The contagiousness of the disease is a paramount consideration at all levels of standard development.

Where From Here?

This fourth draft is for the consideration of experts that may wish to assist with the preparation of the model elements that would make for a model building standard.

A drafting committee has been established to caucus and develop potential regulatory protocols that can be used as guidelines for the construction and maintenance of healthcare facilities with the specific emphasis being correlated with peculiarities of the Ebola disease and its transmission. Until further notice those with whom principal drafting responsibilities will lie are:

We require further input from experts in contagious disease transmission to provide commentary and input to develop potential regulatory protocols. Such contribution however must be pro bono as those currently involved are providing their time and expertise on a pro bono basis.[22] [23]

One of the challenges we have faced is that we have not been able to acquire pro-bono assistance from those in the construction industry with experience in medical facilities.

The input from suitably qualified professionals is essential to the further evolution of an evolved standard. To achieve the level of precision included in medical building standards in the developed world it is essential that individuals with that expertise come forth and provide assistance on a pro bono basis. Lacking this assistance we cannot purport to be either conclusive or definitive with respect to the essential elements of this building standard hence the deliberate use of the title ‘draft’.

Where to Send Comment:

Comment can be made on the linked-in sites where this revised standard has been published and also Kim Lovegrove can be contacted directly through Linked-in mail.

[1] Leonard Peruski Director,Global Disease Detection – Central America, US Centers for Disease Control and Prevention:

“People in Africa usually eat bushmeat with no ill effects. But some of the animals that are consumed as bushmeat can harbor deadly diseases. For example, bats carry a whole range of viruses and some species of fruit bats can harbor Ebola. And bats usually are not affected by Ebola, making them an ideal host. Researchers have monitored populations of animals for Ebola and found very few animals with detectable levels of the virus. Since the first recorded Ebola outbreak in 1976 there have been only 30 single “spillover events” from animals into humans. Simply put, it is difficult for the virus to jump the species barrier from animals into humans. So how the Ebola virus “spills over” into humans is not well understood. Many times an intermediate species, such as another primate, is involved, but the best current evidence also indicates that people can get the virus directly from bats. Via their droppings or fruit they have touched, bats can infect other non-human primates or even humans. Humans can thus get Ebola from bats or the handling of bushmeat. But Ebola is not a disease that is spread by eating bushmeat – this is very important. Initial human infections have been usually associated with hunting, butchering, and processing meat from infected animals – for any given contact with bushmeat or bats the risk of infection is very low BUT given the frequency of contact it is inevitable that there will be new emergences of Ebola or even other diseases that the bats harbor or that can be present in bushmeat. The risks are low but the consequences can be severe.”(Commentary provided to drafting team on 9 December 2014)

[1] The initiative and project was originated and is headed up by Conjoint Professor Kim Lovegrove, FAIB, partner of Lovegrove, Smith & Cotton
Lawyers

[2] Dr Roy J. McGroarty, Chairman, Managing Director and CEO at McGroarty International Health Consultants Inc.

[3] http://reliefweb.int/report/guinea/who-director-general-dr-margaret-chan-speech-ebola-virus-disease-outbreak-delivered .

[4] http://www.cdc.gov/media/releases/2014/t0930-ebola-confirmed-case.html .

[5] http://www.un.org/apps/news/story.asp?NewsID=48988#.VDSXL2eSySo .

[6] Mr Sean P. Fay M.S., MA-CEM former military field Hospital Company Commander in the US Army.

[7] WHO update http://apps.who.int/iris/bitstream/10665/136020/1/roadmapsitrep_8Oct2014_eng.pdf?ua=1 .

[8] http://apps.who.int/iris/bitstream/10665/144806/1/roadmapsitrep_3Dec2014_eng.pdf?ua=1

[9] Evidence for Declining Numbers of Ebola Cases — Montserrado County, Liberia, June–October 2014, Centers for Disease Control and Prevention Morbidity and Mortality Weekly
Report, 14 November 2014, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm63e1114a2.htm .

[10] Dr Dirk Brockmann, ‘2014 Ebola Outbreak: Worldwide Air Transportation and Relative Import Risk’ Robert Koch-Institute & Humboldt
University, Berin, http://rocs.hu-berlin.de/D3/ebola/ .

[11] Lawder, David, “Factbox: U.S. funds to fight Ebola now top $1 billion, may rise, Reuters, 13 October 2014,
http://www.reuters.com/article/2014/10/13/us-health-ebola-usa-money-idUSKCN0I223N20141013.

[12] Department of International Development, “UK Secures 1 Billion European Ebola Commitment”, 24 October 2014, https://www.gov.uk/government/news/uk-secures-1-billion-european-ebola-commitment .

[13] Rajagopalan, Megha, “China to send elite army to help fight Ebola in Libera”, Reuters, 31 October 2014, http://www.reuters.com/article/2014/10/31/us-health-ebola-china-idUSKBN0IK0N020141031 .

[15] http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-specimen-collection-submission-patients-suspected-infection-ebola.html .

[16] http://www.cdc.gov/vhf/lassa/

[17] James Yianoulatos Law Graduate (B.Comm/LLB) researcher who assisted with research elements of the draft.

[18] Conjoint Professor Kim Lovegrove, FAIB, partner of Lovegrove, Smith & Cotton Lawyers, Chairman of the Centre for Best Practice Building
Control and President-Elect of the Northern Chapter of the New Zealand Institute of Building

[19] WHO Guidelines Treatment and disposal technologies for health-care waste
http://www.who.int/water_sanitation_health/medicalwaste

[20] http://au.ibtimes.com/articles/569313/20141013/ebola-ultraviolent-light-viruses-dna-rna-dark.htm#.VIUfbDGUdMU

[21] “The concept of a quarantine ward and a separate isolation ward is the correct way to go, but to deal with issues like humidity and natural ventilation (to avoid reliance on AC) then these wards cannot be connected, basically these buildings need to be narrow and offset from one another (this allows them access to the prevailing winds without interfering with each other and minimises the east west exposure and subsequent heat gain), the other issue of concern is the reliance on complex technology, it seems that the decontamination process for staff used by the CDC is not overly complex and a shower down with a chlorine solution is all that is required, the main concern I have is with the flow of suspected cases, confirmed cases and staff within the buildings and the compound and how best to avoid cross contamination as much as possible.” Mr. Geoff Hoare, building designer at Graaph Design Pty Ltd.

22 http://www.pih.org/pages/mirebalais

23 Useful insights and comment has also been proffered by Sean P. Fay M.S., MA-CEM former military field Hospital Company Commander in the US Army.

24 Prepared by Mr. Geoff Hoare, building designer at Graaph Design Pty Ltd.

Conjoint Professor Bob Whittaker AM, Immediate Past President of the Australian Institute of Building, board member of the
Centre for Best Practice Building Control, has endorsed the work that the Centre for Best Practice Building Control and the drafting team is undertaking.

Contributions have been made by Mr. James Yianoulatos Law Graduate (B.Comm/LLB) by way of research, interviewing and
drafting.

Some ideas emanated from an interview with Mr. Polydor Mutombo (PHD in Neglected Tropical Diseases). Mr. Mutombo will be
travelling to West Africa in January as part of his Post Doctorate Studies. Being at the frontline of the Ebola virus will give Mr. Mutombo valuable insights which can hopefully be used to further
the standards.

The support of this drafting initiative that has been formally volunteered by the New Zealand Institute of
Building.