Philippine COVID-19 Living Clinical Practice Guidelines

Institute of Clinical Epidemiology, National Institutes of Health, UP Manila

In cooperation with the Philippine Society for Microbiology and Infectious Diseases
Funded by the DOH AHEAD Program through the PCHRD

IONIZING AIR PURIFIER

RECOMMENDATION
We recommend against the use of ionizing air purifier to reduce COVID-19 transmission in
the community. (Low quality of evidence; Strong recommendation)

Consensus Issues
One of the studies noted that when an area is inhabited, reducing the particulate matter
becomes insignificant once people move within the household, which consequently makes the
ionizing air purifier ineffective. The panel also recognized that the harm caused by this
intervention outweighs its benefit because one of the apparent disadvantages of ionizers is
the emission of ozone, a powerful oxidant that may inflict health hazards through long-term or
high-dose exposure.

EVIDENCE SUMMARY
Is an ionizing air filter effective in reducing SARS-CoV-2 virus
transmission in public spaces with sustained community transmission?
Valentin C. Dones III, PhD, Maria Cristina Z. San Jose, MD, Howell Henrian G. Bayona, MSc,
CSP-PASP

Key Findings
No direct evidence was found assessing the effectiveness of ionizing air filters in reducing SARS-
CoV-2 infections. Five experimental studies reported using an ionizing air purifier in reducing
airborne particles, mostly in uninhabited laboratory settings. Ionizing air purifiers can efficiently
remove the fine and ultrafine particles. However, its effectiveness in eliminating airborne
organisms for infection control is lacking. Ozone, a dangerous respiratory irritant produced by
some ionizing air purifiers, is a health risk to users. Overall quality: Most of the studies were at
high risk of bias, with common issues on selecting tested ionizing air purifiers and the assessor's
blinding.

Introduction
Ion air generators are among the variety of portable air cleaners used to improve indoor air quality
[1]. Their operating principle is ion emission through corona discharge. Aerosol particles are
repelled and become heavier as they attract negatively charged ions emitted by the air purifier,
causing them to precipitate onto surfaces [2].

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Review Methods
After a thorough search on PUBMED, the Cochrane CENTRAL, ChinaXiv, MedRxiv, National
COVID-19 Clinical Evidence Task Force, COAPLiving Evidence on COVID-19, NIH. US National
Library of Medicine. ClinicalTrials.gov, and Chinese Clinical Trial Registry, there was a systematic
review and five experimental studies. No randomized controlled trials reporting the effects of
ionizing air filters on quarantined individuals were found after a comprehensive literature search
of various electronic databases last January 31, 2021. We also excluded studies that used other
air filters (e.g., high-efficiency particulate air (HEPA) filter), articles not written in English, and
other types of articles (e.g., abstracts, posters, review articles, book chapters, letters, guidelines,
points of view).

Results
No clinical studies were found assessing the effectiveness of ionizing air filters in preventing or
reducing COVID-19 infections. Five experimental studies reported using ionizing air purifiers in
reducing airborne particles, mostly in uninhabited laboratory settings. Although ionizing air
purifiers were efficient in removing fine and ultrafine particles, none of these studies reported its
effects on reducing SARS-CoV-2 viral load, either in laboratory or actual clinical settings [2–6].
Appendix 2 summarizes the ionizing air purifier's benefit (i.e., particle removal efficiency) and
harm (i.e., ozone development).

One of the 5 experimental studies reported that commercial ionizing air purifiers in a residential
apartment did not significantly reduce the particulate matter (PM) size, with an average
indoor/outdoor mass concentration ratio from 1.03 to 0.73 for most PM size fractions [2]. In
experimental chambers, however, ionizing air purifiers alone or with heating, ventilation, and air
conditioning (HVAC) effectively reduced PM concentrations [2–5]. Ion emission increased the
filter collection efficiency for bacteriophage MS2 virus [4], bacteria (B. subtilis, E. coli) by as much
as 3 to 4 times and for viable fungal spores (A. versicolor, A niger) by a factor of 2 [6]. Units with
higher ion emission rates provided higher particle removal efficiency [3–5]. Due to its high ion
emission rates, bipolar ions are better by 1.7x than unipolar ions in removing PM [4].

One disadvantage of ionizers is ozone emission, a powerful oxidant that may harm health by long-
term or high-dose exposure. Factors found to be associated with higher ozone levels include
longer duration of exposure, higher ion emission, and use of bipolar ions. Compared with unipolar
ions, bipolar ions can emit up to 30 ppb compared to unipolar ion's 2-10 ppb ozone concentration
[4]. Ozone exposure was found to be negligible within 2 hours, but significantly increased to > 77
ppb after 8 hours of exposure [2]. Ozone levels also varied across different commercially available
ionizer models despite similar exposure times [5].

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Recommendations from Other Groups

No guideline or agency has explicitly recommended the use of ionizing air purifiers. The US-CDC
acknowledged bipolar ionizers as emerging technologies used in HVAC systems or portable air
cleaners, but mentioned limited research supporting its effectiveness outside laboratory
conditions [7].

Research gaps
No study reports the effects of ionizing air purifiers in reducing or eliminating SARS-CoV-2 in the
community. No on-going studies are addressing this research gap.

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References
[1] US EPA. RESIDENTIAL AIR CLEANERS A Technical Summary [Internet]. 2018.
Available from: https://www.epa.gov/sites/production/files/2018-
07/documents/residential_air_cleaners_-_a_technical_summary_3rd_edition.pdf
[2] Berry D, Mainelis G, Fennell D. Effect of an Ionic Air Cleaner on Indoor/Outdoor Particle
Ratios in a Residential Environment. Aerosol Science and Technology. 2007
Apr;41(3):315–28.
[3] Grinshpun SA, Mainelis G, Trunov M, Adhikari A, Reponen T, Willeke K. Evaluation of
ionic air purifiers for reducing aerosol exposure in confined indoor spaces. Indoor Air. 2005
Aug;15(4):235–45.
[4] Hyun J, Lee S-G, Hwang J. Application of corona discharge-generated air ions for filtration
of aerosolized virus and inactivation of filtered virus. Journal of Aerosol Science. 2017
May;107:31–40.
[5] Shi S, Zhu S, Lee ES, Zhao B, Zhu Y. Performance of wearable ionization air cleaners:
Ozone emission and particle removal. Aerosol Science and Technology. 2016 Mar
3;50(3):211–21.
[6] Huang R, Agranovski I, Pyankov O, Grinshpun S. Removal of viable bioaerosol particles
with a low-efficiency HVAC filter enhanced by continuous emission of unipolar air ions.
Indoor Air. 2008 Apr;18(2):106–12.
[7] US EPA. Air Cleaners, HVAC Filters, and Coronavirus (COVID-19) [Internet]. 2021.
Available from: https://www.epa.gov/coronavirus/air-cleaners-hvac-filters-and-
coronavirus-covid-
19#:~:text=Central%20furnace%20or%20HVAC%20filters,virus%20that%20causes%20
COVID%2D19.

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Appendix 1. Characteristics of Included Studies

Author, year Particle/Bioaerosols Ionizer air Comparator Outcomes
purifier
Hyun et al. Aerosolized Carbon-fiber NA Overall filtration
(2017)(4) bacteriophage MS2 ionizer of a efficiency
medium air filter
Pressure drop
Antiviral efficiency

Ozone concentration
Shi et al. Particles 4 wearable NA Ozone concentration
(2016)(5) ionizers
PM2.5 concentration
Particle size
distribution
Mass removal rates

Huang et al. B-subtilis, E. coli, A. Ionizer and NA Aerosol concentration

(2008)(6) versicolor, A. niger HVAC
Removal efficiency

Berry et al. Particles Commercially NA Indoor/outdoor

(2007)(2) available ionic airborne particle
air cleaner number
Mass concentration
ratios
Indoor ozone levels
Ion concentration
levels

Grinshpun et NaCl, PSL, five ionic air NA Concentration decay

al. (2005)(3) Pseudomonas purifiers (two of respirable particles
fluorescens bacteria wearable and
three stationary
Particle removal
efficiency

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Appendix 2. Ionizing air purifier's benefit and harm

Outcomes Study Basis Effect Estimate Level of evidence
Particle removal efficiency 4, experimental Low1
Model 1: 15% in 15 min, 30–40% in 1 h, 50% after 1.5 h, 80% after 3 h
(household)
Grinshpun et al, 2005 (3) Model 2: 50% in 15 min, 100% in 1.5 h
Model 3: almost 90% within 5-6 min, 100% within 10-12 min
Particle removal efficiency
(commercially available PM2.5 mass removal rates:
wearable air purifier)
Shi et al., 2016 (5) AC1: 1.85 h-1
AC2: 0.48 h-1
AC3: 1.52 h-1
AC4: 5.37 h-1
Particle removal efficiency:
B-subtilis: 16.4±5.3 to 80.4±14.3%
(with low efficiency HVAC)
E. coli: 17.6±4.2 to 73.3±11.1%
Huang et al. 2008 (6)
A. versicolor: 83.1±12.3%
A. niger: 96.5±10.1%
Filter only: 9.09±4.84%
Particle removal efficiency
Unipolar ions: 46.1% at 15 min, 78.8% at 30 min, and 83.7%, at 45 min
(unipolar vs. bipolar)
Bipolar ions:
Hyun et al, 2017(4) 64.3% at 15 min
89.1% at 30 min
97.4% at 45 min
3, experimental Unipolar air ions emit 2-10 ppb ozone, whereas bipolar air ions emit 30 ppb Low1
Ozone levels (unipolar vs. Hyun, 2017 (4)
ozone.
bipolar)
Shi, 2016 (5) The 10-h average ozone emission rates:

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Outcomes Study Basis Effect Estimate Level of evidence

AC1: 0.67 mg.h-1
AC2: 3.40x 10-2 mg.h-1
AC3/AC4: negligible.
Negligible ozone emissions in 2 hours
Berry, 2007 (2)
1st hour: 13-19 ppb in the 1st hour
≥8 hours: 77 ppb
1 The studies offered indirect evidence and inconsistent findings on the effects of ionizers in laboratory and real-environment settings. The tested ionizers were not systematically selected.
Assessors were not blinded to ionizers used; however, the included studies used objective outcome measures.

Legends: HVAC, heating, ventilation aircon; ppb, part per billion; h-1, the number removal rates of total particles measures in size range from 18.1 to 289 nm

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Ionizing Air Purifier As of 26 February 2021