Effect of ventilation improvement during a tuberculosis outbreak in underventilated university buildings
Open accessAbstract
The role of ventilation in preventing tuberculosis (TB) transmission has been widely proposed in infection control guidance. However, conclusive evidence is lacking. Modeling suggested the threshold of ventilation rate to reduce effective reproductive ratio (ratio between new secondary infectious cases and source cases) of TB to below 1 is corresponding to a carbon dioxide (CO2) level of 1000 parts per million (ppm). Here, we measured the effect of improving ventilation rate on a TB outbreak involving 27 TB cases and 1665 contacts in underventilated university buildings. Ventilation engineering decreased the maximum CO2 levels from 3204 ± 50 ppm to 591-603 ppm. Thereafter, the secondary attack rate of new contacts in university dropped to zero (mean follow-up duration: 5.9 years). Exposure to source TB cases under CO2 >1000 ppm indoor environment was a significant risk factor for contacts to become new infectious TB cases (P < .001). After adjusting for effects of contact investigation and latent TB infection treatment, improving ventilation rate to levels with CO2 <1000 ppm was independently associated with a 97% decrease (95% CI: 50%-99.9%) in the incidence of TB among contacts. These results show that maintaining adequate indoor ventilation could be a highly effective strategy for controlling TB outbreaks.
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Lack of ventilation in homes has been shown to contribute to the transmission of tuberculosis, and maintaining adequate indoor ventilation can effectively control TB outbreaks.
“Lack of ventilation in homes has been shown to contribute to the transmission of tuberculosis (TB) (5); maintaining adequate indoor ventilation can effectively control TB outbreaks (34).”
From Review of the Impact of Housing Quality on Inequalities in Health and Well-Being (2023) · cites this paper as [34]
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Zhang, S., Li, Y., & Lin, Z. (2024) · Indoor Environment and Sustainable Building/Indoor environment and sustainable building · doi:10.1007/978-981-97-6855-4_17
Regad, M., Forin, J., Baudet, A., Lizon, J., & Florentin, A. (2025) · L Aide-Soignante · doi:10.1016/j.aidsoi.2024.12.007
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An overview of CO2 level as an infection risk proxy for different indoor environments in Istanbul
Ayvaz, C., Şahin, Ü. A., Yıldız, E., Demirci, Ş., Özcan, K., Uzun, B., Aydın, D., Onat, B., & Sivri, N. (2026) · Air Quality Atmosphere & Health · doi:10.1007/s11869-026-01903-y
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Analytical Screening of Low-cost CO₂ Sensors for Clinical Infection Control Applications
Ishigaki, Y., Enoki, K., & Yokogawa, S. (2026) · Journal of Clinical Engineering · doi:10.1097/jce.0000000000000755
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Surrogate for Ventilation for Infection Control: Using Carbon Dioxide Biomarker
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Dilution Ventilation as the Means for Airborne Infection Control
Singh, R., Madaan, N., & Dewan, A. (2026) · Springer eBooks · doi:10.1007/978-981-95-8624-0_4
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- Authors
- Du, C., Wang, S., Yu, M., Chiu, T., Wang, J., Chuang, P., Jou, R., Chan, P., & Fang, C.
- Affiliations
- Taiwan Centers for Disease Control (TW)
- Institute of Labor, Occupational Safety And Health, Ministry of Labor (TW)
- Wan Fang Hospital (TW)
- Taipei City Hospital (TW)
- National Taiwan University Hospital (TW)
- National Taiwan University (TW)
- Corresponding author
- Chan, Pei‐Chun
- Fang, Chi‐Tai
- Venue
- Indoor Air
- Publisher
- Wiley
- Published
- 2020-01-16
- Volume
- 30
- Issue
- 3
- Pages
- 422-432
- ISSN
- 0905-6947 (ISSN-L)
- 1600-0668
- PMC
- PMC7217216
- OpenAlex
- W2996980267
- Cited by
- 84
- References
- 31
- Citations by year
- 2026: 8 · 2025: 12 · 2024: 14 · 2023: 17 · 2022: 16 · 2021: 12 · 2020: 4 · 2019: 1
- FWCI
- 6.06
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Indoor Air (publishedVersion, cc-by-nc-nd)
- PubMed Central (publishedVersion, cc-by-nc-nd)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Infection Control and Ventilation
- Physical Sciences › Environmental Science › Health, Toxicology and Mutagenesis › Indoor Air Quality and Microbial Exposure
- Health Sciences › Medicine › Infectious Diseases › Tuberculosis Research and Epidemiology
- Keywords
- tuberculosis outbreak, indoor ventilation, CO2 concentration, secondary attack rate, tuberculosis transmission, university buildings, infection control, ventilation rate, latent tuberculosis infection, TB contacts
- MeSH terms
- Adult, Disease Outbreaks, Female, Humans, Male, Tuberculosis, Universities, Ventilation
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