King County COVID-19 Recovery Indoor Air Program

In the wake of the COVID-19 pandemic, communities around the world faced unprecedented challenges in protecting their health and maintaining a viable economy. King County was no exception. At the start of 2021, as we embarked on a journey towards recovery, Public Health - Seattle & King County’s Environmental Health team launched the King County COVID-19 Recovery Indoor Air Quality Program.  

From 2021 to 2024, we assisted over 3,000 facilities, carried out multilingual outreach, and distributed over 8,500 portable High-Efficiency Particulate Air (HEPA) air cleaners and over 4,500 box fan filter kits with MERV13 filters. This multipronged approach was invaluable in restoring health, comfort, and peace of mind to residents.

This story chronicles our groundbreaking effort to improve indoor air quality and the lessons we learned along the way.  

The pandemic recovery thrust King County into uncharted territory, demanding a dual focus: reopening the economy while safeguarding public health. As Washington state mandates lifted in spring 2021, an unexpected Delta variant of the COVID-19 virus raced across the globe. Recognizing the role of indoor air in virus transmission early on, the Environmental Health team sought a solution to both help address health concerns and contribute to a renewed sense of safety and normalcy.  

Our work started with the release of the  Guidance on Improving Indoor Air Quality for Building Operators and Business Owners . Ahead of any available guidance at the time, it spoke to the needs of key vulnerable indoor spaces: homeless shelters, other congregate housing (such as adult family homes), schools, childcares, small restaurants, other small businesses, and faith organizations. Grappling with how to reopen and gather again safely, these sectors became the focus of our effort. We first prioritized reaching those in south Seattle and south King County – a region unfairly impacted by the COVID-19 pandemic and longstanding environmental health inequities. Over time, we expanded our support to all of King County.

As vaccinations began to roll out, the Environmental Health team pivoted from educating restaurant owners about COVID-19 mandates to assisting our priority sectors with their indoor air quality questions and needs. By mid-2021, we secured $3 million in Federal COVID-19 relief funding solely for indoor air quality issues – an enormous jump from $300,000 available the prior year. As with many other public health agencies, indoor air quality assistance had been a longstanding gap in our services. In the recovery mode, we found ourselves building the plane while flying it! 

Within a few months following the Delta wave, we procured thousands of  portable High Efficiency Particulate Air (HEPA) cleaners.  We also grew a multidisciplinary team of technical assistance (TA) field staff, community educators, logistics and data coordinators, program managers, and leadership. Our team peaked at 15 staff deployed to this effort in the winter of 2021/2022, at the height of the newly emerged Omicron variant surge. 

Building team capacity was key. Experts from  Washington State Department of Health  and  University of Washington  trained the TA field team. Cross-training in the field became the model to quickly expand our knowledge and capacity. 

Tools and protocols helped organize our work, including: 

• an intake request form.
• an onsite indoor air quality assessment.
• a process flow for delivery of portable air cleaners.

We stayed nimble, adapting, and improving as we navigated the everchanging landscape of the pandemic. We quickly responded to community needs as they arose, knowing the best solutions came from those working in the field.  

Our collaborative spirit and interdisciplinary approach were central to the program’s success. We quickly overcame traditional siloes and worked in concert with critical partners within our agency and in the community. We collaborated with community-based organization partners, outbreak investigators, and other programs for referrals and to get the word out.  

Warehouse Team 

King County staff at the warehouse played a crucial role in the logistical aspect of the program by delivering portable HEPA air cleaners and hosting pick-up events. Their efforts ensured the efficient distribution of portable HEPA air cleaners to thousands of facilities across King County. 

Community-Based Organization Partners  

Seven community-based organizations (CBOs) – also known as our “Childcare CBO Partners” – were instrumental in helping to distribute portable HEPA air cleaners to over a thousand childcare providers, ensuring safe environments for children and staff. They focused on reaching home-based childcare providers and childcare centers who serve low-income families. Additionally, multilingual outreach by nine other BIPOC-led CBOs helped to identify and refer small restaurants, small businesses, and faith organizations for indoor air quality technical assistance. Together, we strived to improve access to our program resources and support across the diverse communities. 

Homeless Response HEART Team 

Notably, the Health Engagement Action Resource Team (HEART) brought on environmental health investigators to work alongside public health nurses and community health workers. This interdisciplinary team provided timely essentials and support to our unhoused residents during the pandemic.  

With many shelters in old buildings with poor ventilation, the HEART team forged the way for our first indoor air quality assistance. The team assessed the indoor air quality and ventilation of shelters and placed over 3,000 portable HEPA air cleaners in them.  The University of Washington’s Department of Environmental & Occupational Health Sciences partnered with our team to assess the effectiveness of the portable HEPA air cleaners at the shelters . The study found that the portable HEPA air cleaners were an effective short-term solution to reduce indoor particle levels in homeless shelters during non-wildfire seasons. 

Climate & Health Equity Team 

Public Health-Seattle & King County’s Climate & Health Equity Initiative team had a parallel indoor air quality effort focused on residents. They teamed up with multiethnic community-based partners to train and give away over 4,500  box fan filter kits (BFFs) with 1-inch MERV 13 filters  to vulnerable households. This is an easy do-it-yourself (DIY) option to clear indoor air, particularly if portable HEPA air cleaners are not accessible. However, this DIY kit has its limitations: one BFF kit of this size is most suitable for use in a small single room (150 square foot) and where the fan noise may not be a concern. For additional tips, see  US EPA’s Research on DIY Air Cleaners to Reduce Wildfire Smoke Indoors .  

Education was another cornerstone of our collective success. This took many forms:  

• Site visits at various facilities by the Environmental Health team and the HEART team provided one-on-one technical assistance. 
• Community outreach events and warehouse pick-up events combined one-on-one education with the distributions of HEPA air cleaners and box fan filter DIY kits. 
• Multilingual communication campaign through social media, ethnic media, and postcard mailings helped spread the word quickly. 
• Participants of webinar trainings for restaurant owners and childcare providers received at least one HEPA air cleaner. 
• Trusted community-based organization partners were critical in outreaching to harder-to-reach groups. 
• Production of  educational videos  helped to make the information more accessible. 
• Coverage by multiple local  news media  helped shed light on the importance of indoor air quality. 

Technical Assistance (TA) site visits turned out to be the most powerful way to promote healthy indoor air. By walking through the facility, environmental health staff could assess ventilation (air flow) and recommend common best practices. They could also demonstrate how to use and maintain a portable HEPA cleaner and discuss how many were needed and where to place them to be most effective.  

Check out the  KOMO NEWS TV reporting on our indoor air technical assistance effort .

Making improvements to indoor air quality wasn’t always easy. Childcare providers had concerns about safety related to the recommendation of opening windows. Some sites struggled to increase natural ventilation because of nearby highway pollution. For small businesses and restaurants, their building managers or landlords didn’t always maintain and clean HVAC systems or make repairs that would benefit indoor air quality. Many also had aging infrastructure and financial constraints for improving their spaces. 

Given these barriers, portable High Efficiency Particulate Air (HEPA) cleaners became the most effective and simple solution. The Environmental Health team, HEART team, and our Childcare CBO Partners worked in parallel to distribute portable HEPA air cleaners. The HEART team worked closely to meet the indoor air needs of homeless shelters. And these seven Childcare CBO Partners successfully provided over a thousand small-scale childcare providers with one HEPA air cleaner each: Child Care Resources, El Centro de la Raza, Center for MultiCultural Health, White Center Community Development Association, Korean Community Service Center, Kandelia, and Iraqi Community Center of Washington.

The Environmental Health team used an equity and risk-based criteria checklist as an initial screening tool to help prioritize where portable HEPA air cleaners went to. Using a tiered approach, we first prioritized those with barriers to improving indoor air quality and ventilation on their own, and located in areas with higher COVID positive rates, long-standing air pollution burden, and/or lower rates of vaccination at that time. This geographic focus was south Seattle and south King County, with priority also given to sites undergoing outbreak investigations.

Over three years, our collective efforts have achieved remarkable results during the safe reopening of our local economy. Businesses regained patrons' trust and ensured the well-being of those patrons and their staff, and parents felt secure sending their children to childcares.   

This program launched at a time when the community needs for indoor air quality assistance was the greatest. Demand for our technical assistance and portable HEPA air cleaners began on the heels of the Delta variant surge and peaked during the Omicron surge. During this intense period, we had the most environmental health staff deployed to this effort.  

Multiple efforts worked in parallel to serve the priority sectors across King County:  

• Environmental Health team (EH Team) provided technical assistance (TA) site visits and HEPA air cleaners to all priority sectors: restaurants, homeless shelters, other congregate housing (primarily adult family homes), other small businesses, schools, and childcare sites. These included both those who reached out for support and those who were referred by our outbreak investigation team. 
• Health Engagement Action Resource Team (HEART Team) focused technical assistance and HEPA air cleaners for homeless shelters, which were located mostly in the Seattle area. 
• Seven Childcare CBO Partners targeted distribution of portable HEPA air cleaners to home-based childcares and childcare centers that served low-income households. They did not have staff capacity to provide education or technical assistance.  

This map depicts our geographical reach in King County. It is based on the number of sites served and the number of portable HEPA air cleaners distributed by the EH team, HEART team, and the Childcare CBO Partners from 2021 through the end of 2023.  

What We Learned from Our Recipients 

Following most of our technical assistance work and supply distribution, we surveyed our recipients in December 2022 to capture their feedback. We wanted to learn how well our program was doing, what perceived benefits the recipients gained, and what challenges recipients may have with making indoor air improvements. Only 11% responded to the survey (123 responses out of 1,129 surveyed) so the results may not represent those who did not respond. Nevertheless, the survey did shed some light on how well we were doing so far.  

Overall, most of the survey participants felt the program was helpful because: 

• They became more knowledgeable about indoor air quality and how it affects their health. 
• They felt safer when using the HEPA cleaner or following the advice given.  
• They noticed improvement in the indoor air quality.  

King County's COVID-19 Recovery Indoor Air Quality Program stands as a testament to resilience and ingenuity. We embraced adaptive solutions, strengthened collaborations, and centered equity. As a result, our staff, partners, and community members helped pave the way for a renewed, healthier future. And our commitment to community resiliency remains unwavering, setting a model for others.  

In 2022, the National Association of County and City Health Officials (NACCHO) recognized the program with a  Bronze Innovative Practice Award  for meeting the needs of the communities during the COVID-19 pandemic.  

During the last six months of the program (January to June 2024), we focused on transitioning elements of indoor air quality work to other relevant programs (such as asthma prevention, school environmental health, climate, homeless coordination, and childcare health education). Most will carry out indoor air quality education when there was little or none before. A few will have staff and funding to continue direct technical assistance and/or offer portable HEPA air cleaners to their specific sectors.  

For those interested in standing up a similar indoor air quality program, we recommend: 

• Ensuring direct technical assistance accompanies the distribution of portable HEPA air cleaners. This will assure recipients gain the knowledge and skills to improve indoor air quality at their specific site. 
• Offering training videos and webinars (in preferred languages) to help sustain and diffuse the messages throughout the community. Facilities, such as homeless shelters, may have high staff turnover and the videos can help train new staff. Childcare providers will value receiving continuing education credits for attending the trainings. 
• Hosting pick-up events at a warehouse with technical assistance staff on-hand when time is limited.  
• Partnering with trusted community-based organizations, housing authorities, and other groups to outreach to harder-to-reach groups. 

Long-Term Needs 

While our COVID-recovery effort has reached its conclusion in June 2024, the need for vigilance and action remains steadfast. The pandemic has taught us how indoor air quality can profoundly impact human health, productivity, and overall well-being. The sunset of our program marks not an end, but a transition—a call to arms for continued focus and dedication. Indoor air quality is not a temporary concern; it's an ongoing necessity. 

As local health jurisdictions, we must strive to achieve healthy indoor environments for all. Daily exposures to poor indoor air quality can pose health risks, particularly for our most sensitive populations (such as people with asthma). We must stand ready to tackle potential new airborne pathogens – and help foster community resilience in the face of climate change-fueled wildfires. And we must strive for more health-protective standards related to indoor environments. 

This starts with a need for renewed and long-term investments in indoor air quality. Sustainable funding can ensure we have a dedicated team of trained environmental health staff to respond to indoor air quality complaints and emergencies. Grants and other financial support are also essential to help facilities make critical infrastructure improvements (such as HVAC upgrades) and to sustain long-term community partnerships. 

As community members, we all can continue to  take actions to improve indoor air quality through prevention, ventilation, and filtration . 

Let us carry forward the lessons learned, the innovations forged, and the partnerships nurtured, ensuring that every breath taken indoors is one of purity and vitality. Our program's sunset is not the end of our mission; it's the dawn of a new chapter in our collective commitment to healthier indoor environments for all.