Environmental footprints of disposable and reusable personal protective equipment ‒ a product life cycle approach for body coveralls

Barriers and facilitators to implementing reusable personal protective equipment in hospitals, and their impacts on environment, care safety, costs, and supply chain resilience: a scoping review protocol

INTRODUCTION

Climate degradation poses a significant global health challenge, with healthcare systems paradoxically contributing to this issue while adhering to the principle of 'do no harm'. Notably, the healthcare sector accounts for a considerable share of greenhouse gas emissions in many industrialised countries, primarily due to the supply chain, including pharmaceuticals, disposable medical devices and personal protective equipment (PPE). The COVID-19 pandemic exacerbated this issue, with millions of tons of CO2 emissions attributed to single-use PPE. In response to the pandemic, some hospitals have begun adopting and implementing reusable PPE as a sustainable alternative to reduce emissions, enhance resilience to supply chain disruptions and achieve cost savings. This scoping review aims to synthesise the available evidence on the adoption, implementation barriers and facilitators, as well as the impacts of reusable PPE in hospital settings.

METHODS AND ANALYSIS

This protocol is based on York's five-stage framework outlined by Arksey and O'Malley. We will map evidence on the environmental and economic impacts of reusable versus disposable PPE, and the associated infection risks. Using an adapted Consolidated Framework for Implementation Research, our scoping review will identify enablers and barriers to implementation across different clinical settings. The methodology will adhere to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Review guidelines and will include a comprehensive search of peer-reviewed articles in five databases (Medline, Embase, CINAHL, Web of Science and Global Health) and grey literature. Databases will be searched from inception to December 2024. Two reviewers will independently evaluate the eligibility of all identified titles and abstracts for inclusion in the full-text review, as well as for data extraction. Descriptive data will provide insights into the enablers and facilitators of reusable PPE adoption and implementation, along with its impacts on patient and staff safety, costs, the environment and supply chain resilience to disruptions will be reported.

ETHICS AND DISSEMINATION

We expect the results to both identify research gaps and generate novel ideas for future studies on transitioning to reusable PPE in healthcare settings. This review will offer healthcare decision-makers valuable insights into the factors influencing the shift from disposable to reusable PPE and its associated impacts. By refining PPE management strategies, the findings will enable managers to clearly understand the challenges and anticipated outcomes, thereby guiding effective decision-making and facilitating a smooth transition that minimises operational disruptions while upholding patient and staff safety. Ethics approval was not required for this review. The findings will be shared through conferences on healthcare management and sustainability, and submitted to peer-reviewed journals in healthcare management and implementation science. TRIAL REGISTRATION DETAILS: https://doi.org/10.17605/OSF.IO/DESVU.

Cross-Generational Exposure to Low-Density Polyethylene Microplastics Induced Hyperactive Responses in Eisenia fetida Offsprings

The extensive application of plastic products in daily human life has led to the accumulation of microplastics (MPs) in agricultural soil. However, little is known about the cross-generational toxicity of MPs on terrestrial invertebrates. In this study, two-generational Eisenia fetida was exposed to low-density polyethylene (LDPE, 0-5%, w/w) for 98 days to reveal the cross-generational toxicity and the underlying mechanisms. Results showed that LDPE-MPs not only perpetrated deleterious effects on the development, hatchability, and fecundity of the F0 generation but also stimulated the antioxidant defense activity, inhibited lipid peroxidation, and disordered neurotransmission in F1 generation individuals. The susceptibility of the epidermal-intestinal barrier to LDPE-MPs was dose-dependent. According to the transcriptomic analysis, the cross-generational earthworms confirmed significant perturbances in the cell cycle, neural activity-related pathways, and amino acid metabolism pathways (p < 0.05). Nevertheless, the metabolomic profile of F1 generation individuals exhibited significant hyperactive responses in glutathione metabolism and alanine, aspartate, and glutamate metabolism (p < 0.05). This study provides a comprehensive knowledge of LDPE-MPs toxicity on cross-generational earthworms and highlights the hyperactive responses in the antioxidant defense performance of the offsprings. Our findings also underscore the necessity for long-term investigations in assessing the adverse impacts of emerging pollutants.

Fabrication of multifunctional antibacterial polypropylene via layer-by-layer assembly for potential application in reusable protective suits

The spread of the global epidemic continues to pose a serious threat, and the vast consumption of disposable polypropylene (PP) nonwoven medical protective suits presents significant environmental challenges. Therefore, the development of reusable, antibacterial PP nonwovens holds significant importance. This research presents a multifunctional PP exhibiting bacteria-killing, bacteria-releasing, and anti-bacteria adhesion, fabricated through layer-by-layer assembly utilizing modified sodium carboxymethylcellulose (CMC) and chitosan quaternary ammonium (CTS-QAS). Evaluations demonstrate that the modified PP nonwoven eliminated 99.33 % of Staphylococcus aureus (S. aureus) and 99.95 % of Escherichia coli (E. coli) in 0.5 h. Remarkably, near complete eradication of both S. aureus and E. coli within was observed in 1 h, indicating rapid antibacterial ability. Simultaneously, the material effectively inhibited bacterial attachment and facilitated the release of adhered bacteria through the thermal responsiveness of PNIPAM molecular chains. Furthermore, the modified PP nonwoven demonstrated excellent storage and wash stability, biocompatibility, and rechargeability. Therefore, the modified PP nonwoven holds considerable promise for application in reusable medical protective suits.

Strategies and tactics to reduce the impact of healthcare on climate change: systematic review

OBJECTIVE

To review the international literature and assess the ways healthcare systems are mitigating and can mitigate their carbon footprint, which is currently estimated to be more than 4.4% of global emissions.

DESIGN

Systematic review of empirical studies and grey literature to examine how healthcare services and institutions are limiting their greenhouse gas (GHG) emissions.

DATA SOURCES

Eight databases and authoritative reports were searched from inception dates to November 2023.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Teams of investigators screened relevant publications against the inclusion criteria (eg, in English; discussed impact of healthcare systems on climate change), applying four quality appraisal tools, and results are reported in accordance with PRISMA (preferred reporting items for systematic reviews and meta-analyses).

RESULTS

Of 33 737 publications identified, 32 998 (97.8%) were excluded after title and abstract screening; 536 (72.5%) of the remaining publications were excluded after full text review. Two additional papers were identified, screened, and included through backward citation tracking. The 205 included studies applied empirical (n=88, 42.9%), review (n=60, 29.3%), narrative descriptive (n=53, 25.9%), and multiple (n=4, 2.0%) methods. More than half of the publications (51.5%) addressed the macro level of the healthcare system. Nine themes were identified using inductive analysis: changing clinical and surgical practices (n=107); enacting policies and governance (n=97); managing physical waste (n=83); changing organisational behaviour (n=76); actions of individuals and groups (eg, advocacy, community involvement; n=74); minimising travel and transportation (n=70); using tools for measuring GHG emissions (n=70); reducing emissions related to infrastructure (n=63); and decarbonising the supply chain (n=48).

CONCLUSIONS

Publications presented various strategies and tactics to reduce GHG emissions. These included changing clinical and surgical practices; using policies such as benchmarking and reporting at a facility level, and financial levers to reduce emissions from procurement; reducing physical waste; changing organisational culture through workforce training; supporting education on the benefits of decarbonisation; and involving patients in care planning. Numerous tools and frameworks were presented for measuring GHG emissions, but implementation and evaluation of the sustainability of initiatives were largely missing. At the macro level, decarbonisation approaches focused on energy grid emissions, infrastructure efficiency, and reducing supply chain emissions, including those from agriculture and supply of food products. Decarbonisation mechanisms at the micro and meso system levels ranged from reducing low value care, to choosing lower GHG options (eg, anaesthetic gases, rescue inhalers), to reducing travel. Based on these strategies and tactics, this study provides a framework to support the decarbonisation of healthcare systems.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42022383719.

Life cycle assessment applications to reuse, recycling and circular practices for textiles: A review

To understand which are the best strategies for textile waste management and to analyse the effects on the environment of applying circular economy practices to textile products, a review of 45 publications where life cycle assessment (LCA) is applied to these topics has been carried out. The separate collection of textiles, followed by reuse and recycling brings relevant environmental benefits, with impacts related to reuse resulting lower than those of recycling. At the opposite, when mixed municipal solid waste is addressed to energy recovery, the textile fraction is the second most impacting on climate change, right after plastics, while for landfill disposal impacts textiles directly follow the more biodegradable fractions. Textiles manufacturing using recycled fibres generally gives lower impacts than using virgin ones, with a few exceptions in some impact categories for cotton and polyester. The circular practices with the lowest impacts are those that ensure the extension of the textiles service life. Another aim of this review is to identify the main variables affecting the life cycle impact assessment (LCIA). These resulted to be the yield and material demand of recycling processes, the use phase variables, the assumptions on virgin production replaced by reuse or recycling, the substitution factor in reuse, and transportation data in business models based on sharing. Thus, in LCA modelling, great attention should be paid to these variables. Future research should address these aspects, to acquire more relevant data, based on industrial-scale processes and on people habits towards the circular economy strategies applied to textiles.

Green Physical Modification of Polypropylene Fabrics by Cross-Linking Chitosan with Tannic Acid and Postmodification by Quaternary Ammonium Grafting to Improve Antibacterial Activity

A green cross-linking and straightforward method to physically trap inert fibers in a network of chitosan was implemented. The cross-linking reaction involved a biosourced and biocompatible cross-linker [tannic acid (TA)] and mild conditions in water (pH = 8.5, O2 bubbling, 60 °C, 3 h). The steric hindrance of TA led to a low but effective cross-linking rate leaving parts of primary amines of chitosan available for postmodification such as the grafting of quaternary ammoniums for antibacterial purposes. Fabric's coatings were characterized by scanning electron microscopy coupled with energy-dispersive X-ray, infrared spectroscopy, and weight gain measurements. This allowed the optimization of process conditions. No significant antioxidant activity was observed on fabrics coated with chitosan cross-linked with TA, confirming the low cross-linking rate. This low cross-linking rate allowed grafting of quaternary ammoniums for antibacterial purposes, but it is possible to consider grafting other active molecules. Biological assays were conducted on this coating to assess its antibacterial properties. Reduction of bacterial colonization on both Staphylococcus aureus (Gram-positive) and Escherichia coli (Gram-negative), two of the major strains responsible for nosocomial infections, confirmed the potential of the coating for antibacterial purposes. This study displays a simple and ecofriendly process to coat inert fabrics with a chitosan network containing reactive functions (primary amines) available for grafting active molecules for various purposes.