SARS-CoV-2 indoor contamination: considerations on anti-COVID-19 management of ventilation systems, and finishing materials in healthcare facilities

Abstract

Many of the devastating pandemics and outbreaks of last centuries have been caused by enveloped viruses. The recent pandemic of Coronavirus disease 2019 (COVID-19) has seriously endangered the global health system. In particular, hospitals have had to deal with a frequency in the emergency room and a request for beds for infectious diseases never faced in the last decades. It is well-known that hospitals are environments with a high infectious risk. Environmental control of indoor air and surfaces becomes an important means of limiting the spread of SARS-CoV-2. In particular, to preserve an adequate indoor microbiological quality, an important non-pharmacological strategy is represented by Heating, Ventilation and Air Conditioning (HVAC) systems and finishing materials. Starting from the SARS-CoV-2 transmission routes, the paper investigates the hospital risk analysis and management, the indoor air quality and determination of microbial load, surface management and strategies in cleaning activities, HVAC systems' management and filters' efficiency. In conclusion, the paper suggests some strategies of interventions and best practices to be taken into considerations for the next steps in design and management.

Effectiveness of face masks for the population

Background

Health authorities and organizations consider non-medical face masks as an additional passive means to prevent virus diffusion. Communication strategies disseminate information among the population that such masks are essential for mitigating virus diffusion. However, scientific studies are not conclusive in showing the undisputed filtration efficiency of fabric/cloth facial masks (both commercial and homemade).

Objectives

This study examines scientific data about the effectiveness of face masks before and during the COVID-19 emergency. Present trends in the making of commercial and homemade fabric/cloth face masks are also examined.

Methods

Statistical data of published studies are analyzed and compared. Main considerations and sugge-stions are also extracted and discussed. Current approaches are examined for assessing the characteristics and effectiveness of fabric/cloth commercial and homemade face masks intended for the population.

Results

Conflicting data exist as to whether non-medical masks have a protective effect from the spread of respiratory viruses. Both medical masks (MDs) and respiratory personal protection equipment (PPE) show a given effectiveness value.

Conclusion

Concerning commercial and homemade fabric/cloth masks, giving general indications on the choice of materials and their assemblage is difficult as it is not possible to assess the effectiveness of the filter media with respect to the kind of multiphase fluid that may be emitted upon breathing, sneezing, or coughing under different environmental conditions. This is particularly important because airflow rate, temperature, humidity, and duration of use will affect the performance of filter media. Moreover, while a mask may have excellent filter media, droplets may leak into the face-piece unless there is an adequate facial seal. In the presence of leaks, any type of mask may actually offer less protection independently of its nominal filtering effìciency.

A proposal of hygienic and sanitary standards for the new Building Code in Italy

The traditional emphasis of Public Health on the type and quality of housing today merges with other wider determinants of health such as: the neighbourhood, the community and the "place" where a home is located, but also the policies that make access to a healthy home within everyone's reach. At the neighbourhood scale, context-related aspects heavily influence the internal quality and real usability of the buildings themselves, with particular reference to factors such as the quality of the site, the relationship between the building and the context, the presence and quality of the greenery and open spaces surrounding the building, as well as all measures that make it possible to reduce the building's impact on the environment, to protect it against environmental pollution, and to manage the building in an integrated manner for maintenance purposes. Creating healthy living environments means referring to the different dimensions mentioned above, and this not only requires the attention of Public Health operators, but also implies an integration of vision and objectives among various professional skills and competences that puts health at the center of all policies. This proposal, which starts from the analysis of existing local hygiene regulations and scientific literature, aims to take stock of a number of areas considered fundamental for the assessment of building hygiene aspects, with particular reference to the eco-sustainability of buildings and adaptation to climate change. The aspects identified can be considered as a starting point for the preparation of integrated building and hygiene regulations based on documented effective practices for the protection of Public Health.

Housing spaces in Europe: a comparative analysis of standards in nine European Countries

Introduction

In recent years, Public Health devoted a growing interest to housing conditions. In particular, housing dimensions and functional characteristics are relevant, mainly considering population ageing and disability. Aim of the study is to compare housing standards of some European countries to analyse their ability to satisfy new population needs.

Methodology

The dwellings dimensional standards of 9 European countries (Sweden, UK, Denmark, The Netherlands, France, Germany, Portugal, Spain and Italy) are compared. From the websites of the official channels of the various countries the regulations have been downloaded. The standards have been compared.

Results

A wide variability in the dimensions of room among the standards is observed (e.g. single room: from 9 sqm in Italy, to 7 sqm in France, to the absence of any limit in UK, Germany - Hesse and Denmark). Italian and French regulations define housing dimension considering the room use (eg. bed or living room) and the number of people. The Swedish regulation provides performance requirements and functional indications but does not specify the minimum dimensions of habitable rooms. The rooms' minimum height varies between the standards. In Italy and Portugal, the minimum height of the ceiling is intended to be 2.70 m, while in the other nations the minimum heights vary from 2.60 m in the Netherlands to no limit in UK.

Conclusions

A diverse approach among European Countries is observed: from a market-oriented logic (e.g., UK), in which minimum dimensions are not defined, to a prescriptive one (Italy), to a functionality-oriented (the Netherlands). The regulations of some Countries are health-oriented especially for most fragile social classes, since, defining larger dimensional standard, they reduce the risk of overcrowding, indoor air pollution and mental distress. However, considering the health, social, environmental and economic trends, many of these standards should be revised.

Key messages

Optimal housing standards promote the health and well-being of occupants. Healthy housing, healthy people.

How to foster cities resilient to the COVID-19 pandemic through Urban Health strategies

Background

The ongoing pandemic of COVID-19, which nowadays has exceeded 2.5 million notified infections in the world and about 200,000 deaths, is a strong reminder that urbanization has changed the way that people and communities live, work, and interact, and it's necessary to make the systems and local capacities resilient to prevent the spread of infectious diseases. How we can re-design the concept of Public Health in relation to the built environment and the contemporary cities?

Methods

According to the previous statements and scenario, aim of this paper is to integrate the Urban Health strategic objectives, focusing the possible responses, both immediate and medium-long term, to the current environmental, social, and economic aspects of the “period” of physical distancing.

Results

Immediate Actions are 01. program the flexibility of city schedules; 02. plan a smart and sustainable mobility network; 03. define a neighborhood services' plan; 04. develop a digitization of the urban context, promoting the smart communities; 05. re-think the accessibility to the places of culture and tourism. Medium-long term Actions are 06. design the indoor flexibility of domestic living spaces; 07. re-think building typologies, fostering the presence of semi-private or collective spaces; 08. renovate the basic care services' network; 09. integrate the existing environmental emergency plans, with those related to the health emergencies; 10. improve stakeholders' awareness of the factors affecting Public Health in the cities.

Conclusions

The Decalogue of Public Health opportunities may provide a useful basis for Designers (Architects and Urban Planners), Policy Makers, Public Health experts and Local Health Agencies, in promoting actions and policies aimed to transform our cities in healthier and Salutogenic living environments.

Key messages

The strategies described in this paper are at the basis of a social and infrastructural rethinking of the city, careful to the Welfare and Public Health needs.

The physical distancing imposed, may have amplified population's social and health inequalities.

Changes in walkability in three urban neighborhoods of the city of Rome: a comparison 2009-2019

Introduction

Scientific evidence stresses that more walkable neighborhoods are linked to increased physical activity. Walking Suitability Index of the territory (T-WSI) is an easy method, already validated, to evaluate the walkability on the basis of direct observation. Aim of the study is to compare the walkability indices obtained in three urban neighborhoods of the city of Rome in 2009 and 2019, to evaluate whether the urban redevelopment interventions, performed in the decade, do really promote walkability.

Methods

An audit, through T-WSI, is carried out for each street of a neighborhood. T-WSI audit evaluates 12 indicators subdivided into 4 categories: practicability, safety, urbanity, pleasurableness. The weighted analysis of these indicators gives an overall score of the actual usability of the neighborhood. In this study, 2 different trained surveyors, evaluated T-WSI in three neighborhoods of Rome (San Saba, Sacco Pastore and Tufello-Val Melaina), which differ in socio-economic conditions. Average scores have been compared using t-student.

Results

A considerable improvement was observed in the Sacco Pastore neighborhood final weighted scores (T-WSI scores: from 53.6 in 2009 to 68.3 in 2019, with an increase of 14.7% (p < 0.005). All categories improved, although Safety (T-WSI scores: from 35.0 to 59.3; increase of 24.3% - p < 0.005) and Pleasurableness (T-WSI scores: from 48.5 to 61.4; increase of 12.9% - p < 0.005) show the greatest improvements. It is mainly due to redevelopment works carried out in the neighborhood in the last 10 years, mainly aimed to increase citizen's perceived safety (e.g. signs, crossing protection devices, traffic lights, greenery management) and to remove architectural barriers.

Conclusions

The results show T-WSI is a useful tool in order to measure the effectiveness of the interventions already realized at local level, but it could also contribute to making decisions to develop regeneration projects for degraded areas of the cities.

Key messages

Physical Activity must become a priority and part of a daily routine. Healthy cities, healthy people.

Face masks. Technical, technological and functional characteristics and hygienic-sanitary aspects related to the use of filtering mask in the community

INTRODUCTION

The health emergency caused by the spread of SARS-COV-2 virus has required the adoption of passive measures against contagion, such as social distancing. The use of filtering masks, of the different types available on the market, such as surgical and facial filtering masks (FFP1, FFP2 and FFP3), is also recommended.

OBJECTIVES

The aim of this paper, within the Italian and European regulatory reference framework, is to suggest a rational application of existing methodologies that enable to know and assess the features and/or make a face mask intended to be used by the community. In addition to this, the study aims to provide a correct regulatory framework and useful information for a correct use and disposal of face masks. Another purpose is the assessment of the hygienic, sanitary and regulatory aspects related to the use and disposal of face masks.

METHODS

The analysis of filtering masks is based on the review of scientific literature, the state of art of technology and the filtering means/materials available. Reference is made to filtering mechanisms and devices, the testing methods, the technical, manufacturing and performance features, and to the Italian and European regulatory reference framework. Reference is also made to the hygienic, sanitary and regulatory aspects related to the use and disposal of face masks.

RESULTS

Surgical masks or, alternatively, filtering masks with a filtration efficiency between 90% and 95% for 3-µm particles, are the most practicable choice with minor contraindications. The reusable type of mask is conceptually superior compared to single-use masks, but cleaning procedures to be followed are quite complex and not always described in a clear way.

CONCLUSIONS

The definition of rigorous and repeatable tests on mask filtration capacity, breathability, wearability, duration of use, regeneration, as well as safe disposal methods, are the main way to provide users with correct selection and use criteria. The results must be disclosed and disseminated quickly.

Air bio-contamination control in hospital environment by UV-C rays and HEPA filters in HVAC systems

The contamination of air-handling units is a widespread phenomenon in buildings with air-conditioning systems, including hospitals. The germicide capacity of UV-C rays is known and, in the air-conditioning apparatuses, the UV-C lamps are generally located inside the air ducts. Aim of the paper is to evaluate the effectiveness of UV-C lamps when they are differently placed, i.e. in a position to directly irradiate the HEPA filters surface. We built ad hoc experimental air-conditioning systems, with HEPA filters and UV-C lamps in the two described positions. The results obtained demonstrate that, for disinfection purpose, the direct irradiation of the HEPA filters by UV-C provides better results than irradiation of the air stream and the effectiveness increases when lowering the relative humidity of the air. The survival curves of the tested microorganisms (fungi) show typical tail shaped curves (two steps survival curves). Additional tests using both HEPA filters alone, and HEPA filters plus UV lamps, have been performed measuring the air pressure drop between entrance and exit the HEPA filters and collecting air samples in order to obtain total microbial and fungal count. The results obtained suggest that, at least in experimental conditions described, the radiation on filter surface reduces significantly the microbial load and the pressure drop through the filter, compared to a situation of not-irradiated HEPA filters.

When reporting Nocardia spp is not enough. Brain abscess caused by Nocardia farcinica

Abscesses caused by the genus Nocardia spp are relatively rare, accounting for approximately 2 % of all brain abscesses, but with a significantly higher mortality. Special stains of brain abscess material from a 60-year-old man showed Gram-positive branching bacilli and the presence of long, acid-fast branching filamentous bacilli suggesting Nocardia infection. Presented here is a case of multidisciplinary management of a patient who developed cerebral abscesses by Nocardia farcinica, confirmed by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS), that was susceptible to trimethoprim/sulfamethoxazole, linezolid, imipenem and not susceptible to minocycline. This case highlights the importance of performing subtyping and antimicrobial testing in order to improve clinical and treatment outcomes due to patterns of antibiotics resistance among Nocardia species.

Hygienic Requirements of Urban Living Environment in the Russian Federation and in Italy: a comparison

AIM

Urban planning tries to contain and regulate the uncontrolled growth of cities, encouraging their sustainable development at environmental, social and health levels. In the present work, the authors compare the regulatory frameworks of the Russian Federation and of Italy, with particular attention paid to the urban aspects of living spaces.

METHODS

Considering the extant normative production in the two countries, the authors examine national legislation for Italy and federal legislation for Russia, mainly taking into account the following aspects: urban planning tools and environmental and sanitary protection of living spaces.

RESULTS

Hygienic-sanitary requirements regarding living environment in Russia are essentially expressed by two regulatory systems (SNiP and SanPiN), while in Italy they are regulated by the D.M. 07/05/1975. The main principles of urban planning in Russia are expressed by federal standards, while in Italy they are incorporated in the Municipal General Plan (PRG) and in the various local regulations, where all the superordinate regulations are summarized. Finally, aspects related to environmental quality in both countries are governed by various specific laws (federal and state); a complex system of rules that take into account potential impacts on health and the environment.

CONCLUSIONS

The authors reckon that clear and updated regulatory tools should be developed, especially in Italy that lags behind, regarding the building and urban hygiene, relying on the most recent acquisitions of international scientific literature in order to guarantee the highest standards in Public Health safeguard.

The effectiveness of educational interventions in university training on hospital hygiene: results of action research

BACKGROUND

The Italian Study Group of Hospital Hygiene of the Italian Society of Hygiene, Preventive Medicine and Public Health promoted and conducted a study on teaching hospital hygiene, with particular reference to the prevention and control of healthcare-associated infections, with the aim of developing effective educational material starting from the results collected.

MATERIAL AND METHODS

First of all, a survey was carried out, targeting lecturers in hospital hygiene, with the purpose of investigating their perceptions regarding this issue. The available scientific literature was also reviewed in order to identify effective educational/teaching strategies for the prevention of healthcare-associated infections, so that valid training interventions could be subsequently developed. Finally, a trial-training intervention was implemented, and specific audio-visual teaching material was also tested.

RESULTS

The overall response rate to the survey was 42%, with good country-wide representativeness. The level of awareness of hospital hygiene issues by students resulted higher among trainee nurses (65%) than among medical students (44%). The teaching staff identified alternative educational methodologies to substitute the classical lecture (e.g.: case discussions) and, in most cases, the alternative solution appeared to be preferable. The teaching of hospital hygiene was better integrated with other disciplines and professional training activities in the degree courses for nurses than in those for doctors; the total number of hours assigned to such teaching was variable. The literature review highlighted that various educational approaches are used. The most common are presentations or lectures, but videos, posters, questionnaires and e-learning strategies are also used. Combining different instruments when designing an educational programme has proven to be an effective strategy. The training activity tested was positively evaluated by the participants; the possibility of multidisciplinary exchange of knowledge was particularly appreciated.

CONCLUSION

Having considered the issue of teaching hospital hygiene from the points of view of the different protagonists involved (educators and students), this enabled us to develop useful training material and a proposal for a shared educational intervention. The subject of hospital hygiene, in particular the one related to the prevention of healthcare-associated infections, is addressed in various courses and with different modalities; it is, therefore, important to standardize course contents and teaching methods, in order to facilitate multidisciplinary debate, especially starting from case studies.

Observational study on hospital building heritage and microbiological air quality in the orthopedic operating theater: the IM.PA.C.T. Project

BACKGROUND

The study investigated 35 orthopedic OTs [17 with mixed flow (M-OTs), 18 with turbulent flow (T-OTs)].

METHODS

The OTs were divided into two categories based on recurring architectural and construction solutions, collected by a survey form: type-A (recently built or renovated rooms), and type-B (other OTs). Assessment of microbial air contamination (colony forming units (cfu)/m3 obtained by active sampling via Surface Air System) was then performed.

RESULTS

In 97% of the OTs, a Total Viable Count (TVC) was within the limits recommended by ISPESL 2009; all A-type OTs, and 94% of B-type passed. The TVC of type-A OTs [median 15 cfu/m3, range 3-158] was lower than that of type-B OTs [median 28 cfu/m3, range 6-206], although the difference was not significant. The number of people in type-A [mean 8.6, range 6-11] was lower than in type-B [mean 9.6, range 7-13] OTs, and when adjusted to the volume of the OT (person/m3), showed a significant correlation with TVC (ρ = 0.383, p <0.05).

CONCLUSIONS

In conclusion, the structural factors examined do not appear to significantly affect the microbiological air quality at the specific sampling point. However, further investigations are required to identify the factors that have the greatest effect on TVC.

Definition of criteria and indicators for the prevention of Healthcare-Associated Infections (HAIs) in hospitals for the purposes of Italian institutional accreditation and performance monitoring

BACKGROUND

Healthcare-associated infections (HAIs) are an important issue in terms of quality of care. HAIs impact patient safety by contributing to higher rates of preventable mortality and prolonged hospitalizations. In Italy, analysis of the currently available accreditation systems shows a substantial heterogeneity of approaches for the prevention and surveillance of HAIs in hospitals. The aim of the present study is to develop and propose the use of a synthetic assessment tool that could be implemented homogenously throughout the nation.

METHODS

An analysis of nine international and of the 21 Italian regional accreditation systems was conducted in order to identify requirements and indicators implemented for HAI prevention and control. Two relevant reviews on this topic were further analyzed to identify additional evidence-based criteria. The project team evaluated all the requirements and indicators with consensus meeting methodology, then those applicable to the Italian context were grouped into a set of "focus areas".

RESULTS

The analysis of international systems and Italian regional accreditation manuals led to the identification respectively of 19 and 14 main requirements, with relevant heterogeneity in their application. Additional evidence-based criteria were included from the reviews analysis. From the consensus among the project team members all the standards were compared and 20 different thematic areas were identified, with a total of 96 requirements and indicators for preventing and monitoring HAIs.

CONCLUSIONS

The study reveals a great heterogeneity in the definition of accreditation criteria between the Italian regions. The introduction of a uniform, synthetic assessment instrument, based on the review of national and international standards, may serve as a self-assessment tool to evaluate the achievement of a minimum standards set for HAIs prevention and control in healthcare facilities. This may be used as an assessment tool by the Italian institutional accreditation system, also useful to reduce regional disparities.

Strategies for Disease Prevention and Health Promotion in Urban Areas: The Erice 50 Charter

The Erice 50 Charter titled "Strategies for Diseases Prevention and Health Promotion in Urban Areas" was unanimously approved at the conclusion of the 50th Residential Course "Urban Health. Instruments for promoting health and for assessing hygienic and sanitary conditions in urban areas", held from 29th March to 2nd April 2017 in Erice, at the "Ettore Majorana" Foundation and Centre for Scientific Culture and promoted by the International School of Epidemiology and Preventive Medicine "G. D'Alessandro" and the Study Group "Building Hygiene" of the Italian Society of Hygiene, Preventive Medicine and Public Health (SItI). At the conclusion of the intense learning experience during the Course, with more than 20 lectures, workshops and long-lasting discussions between Professors and Students, the participants identified the major points connecting urban features and Public Health, claiming the pivotal role of urban planning strategies for the management of Diseases Prevention and Health Promotion activities. The Erice 50 Charter is configured as a Decalogue for Healthy Cities and as a Think Tank for designing effective strategic actions and best practices to develop urban regeneration interventions and improve the urban quality of contemporary cities. The Decalogue is structured into the following key strategic objectives: 1. Promoting urban planning interventions that address citizens towards healthy behaviours; 2. Improving living conditions in the urban context; 3. Building an accessible and inclusive city, with a special focus on the frail population; 4. Encouraging the foundation of resilient urban areas; 5. Supporting the development of new economies and employment through urban renewal interventions; 6. Tackling social inequalities; 7. Improving stakeholders' awareness of the factors affecting Public Health in the cities; 8. Ensuring a participated urban governance; 9. Introducing qualitative and quantitative performance tools, capable of measuring the city's attitude to promote healthy lifestyles and to monitor the population's health status; 10. Encouraging sharing of knowledge and accessibility to informations. Finally, all the participants underlined that a multidisciplinary team, composed of Physicians specialized in Hygiene, Preventive Medicine, Public Health and Technicians as Architects, Urban planners and Engineers, is needed to deepen the research topic of Urban Health.

Public health and urban planning: a powerful alliance to be enhanced in Italy

Urban planning has played and still plays a key role in improving urban health and indoor health. The authors sketch out the historical evolution of the relationships between Public Health and urban planning, in particular to what happened in Italy during the past 150 years. The authors suggest some lines for further research, but also describe some interventions that could obtain practical results in terms of health gains for the population.

Risk of surgical site infections following hip and knee arthroplasty: results of the ISChIA-GISIO study

BACKGROUND

Surgical Site Infection (SSI) is one of the major complications following insertion of hip or knee prosthesis. The aim of the present study was to describe rates of SSIs and associated risk factors during hip and knee prosthesis procedures in Italian hospitals.

METHODS

Italian hospitals were invited to join the ISChIA (Surgical Site Infections in Arthroplasty Surgery) project and participated in the study on a voluntary basis. SSI surveillance was performed according to the Hospitals in Europe Link for Infection Control through Surveillance (HELICS) -SSI protocol. The study population consisted of all patients who had a prosthetic knee or hip joint replacement between March 2010 and February 2011. Only elective operations were include.

RESULTS

A total of 14 hospitals and 1285 surgical procedures were included. SSI cumulative incidence was 1.3 per 100 hip and 2.4 per 100 knee surgical procedures; a significant positive trend of SSI incidences was observed with increasing SSI risk index. In multivariate analysis, considering hip procedures, the single independent risk factor associated to SSI was operation length (RR: 4.54; 95%CI: 1.06-19.48). For knee procedures, no significant risk factor was identified.

CONCLUSIONS

In the present study, SSI cumulative incidence was in the range of European data. However, a larger number of operations is needed to better estimate SSI rates. A second edition of the ISChIA project has been already conducted and results of the two surveys will provide new insight to further our knowledge for infection control.

Water safety in healthcare facilities. The Vieste Charter

The Study Group on Hospital Hygiene of the Italian Society of Hygiene, Preventive Medicine and Public Health (GISIO-SItI) and the Local Health Authority of Foggia, Apulia, Italy, after the National Convention "Safe water in healthcare facilities" held in Vieste-Pugnochiuso on 27-28 May 2016, present the "Vieste Charter", drawn up in collaboration with experts from the National Institute of Health and the Ministry of Health. This paper considers the risk factors that may affect the water safety in healthcare facilities and reports the current regulatory frameworks governing the management of installations and the quality of the water. The Authors promote a careful analysis of the risks that characterize the health facilities, for the control of which specific actions are recommended in various areas, including water safety plans; approval of treatments; healthcare facilities responsibility, installation and maintenance of facilities; multidisciplinary approach; education and research; regional and national coordination; communication.

Lighting requirements of dwellings: a comparison between Russian federation and Italy

Good lighting is a key factor for indoor health and wellness. Hygienic regulations regarding illumination requirements have been elaborated much time ago and in different countries. The authors describe these requirements in Italy and in the Russian Federation, analysing their contents and issues and comparing them. The results show that the Russian ones are updated, more precise and complete. In conclusion, the authors stress the strong need for a revision and update of the specific Italian hygienic and sanitary regulations.