Open defecation and squat toilets, an overlooked risk of fecal transmission of COVID-19 and other pathogens in developing communities

Missed nursing care and related factors: a cross-sectional study

BACKGROUND

Nurses facing numerous responsibilities in hospitals are often forced to prioritize nursing care. Missed nursing care affects nurses' ability to effectively manage, oversee, and assess patient care interventions and may contribute to unfavorable patient outcomes. Awareness of missed nursing care is essential for improving patient care and nursing performance and optimizing the work environment. Research on the factors contributing to missed nursing care is essential for implementing targeted strategies. This study aimed to determine missed nursing care and its related factors in Iran.

METHODS

This cross-sectional study involved 189 nurses. Two questionnaires on missed nursing care and related factors were used for the data collection. Mann-Whitney U test and one-way ANOVA or Kruskal-Wallis test were used to analyze the data.

RESULTS

The mean (SD) of nurses' age was 31.19 (6.4). The mean of missed nursing care was 6.4 (SD = 31.1), which was higher than the median of the questionnaire. The most frequently reported missed care was toilet monitoring (23.3%) and setting up food (19.6%). The total mean score of factors related to missed nursing care was 11.6 (SD = 68.7), which was lower than the median of the questionnaire. The factors related to missed nursing care included engaging the nurse with other actions (76.7%) and an inadequate number of staff (76.2%). There was a significant association between the mean MNC score and participants' age (P < 0.001), work experience (P = 0.002), and employment type (P < 0.001).

CONCLUSION

Given the severe nursing shortage and its potential negative impact on patients, healthcare management and policymakers need to address missed nursing care. Proposed solutions to alleviate the nursing staff shortage include enhancing the work environment, increasing nurse recruitment opportunities, and improving their compensation and benefits packages. Additionally, there is a need for governmental and hospital initiatives to enhance the working conditions through increased financial investment and support programs for nurses. Management should focus on minimizing nurses' non-essential responsibilities and supporting efforts to reduce missed nursing care occurrences.

Detection of biological loads in sewage using the automated robot-driven photoelectrochemical biosensing platform

Real-time polymerase chain reaction (RT-PCR) remains the most prevalent molecular detection technology for sewage analysis but is plagued with numerous disadvantages, such as time consumption, high manpower requirements, and susceptibility to false negatives. In this study, an automated robot-driven photoelectrochemical (PEC) biosensing platform is constructed, that utilizes the CRISPR/Cas12a system to achieve fast, ultrasensitive, high specificity detection of biological loads in sewage. The Shennong-1 robot integrates several functional modules, involving sewage sampling and pretreatment to streamline the sewage monitoring. A screen-printed electrode is employed with a vertical graphene-based working electrode and enhanced with surface-deposited Au nanoparticles (NPs). CdTe/ZnS quantum dots (QDs) are further fabricated through the double-stranded DNA (dsDNA) anchored on Au NPs. Using the cDNA template of Omicron BA.5 spike gene as a model, the PEC biosensor demonstrates excellent analytical performance, with a lower detection limit of 2.93 × 102 zm and an outstanding selectivity at the level of single-base mutation recognition. Furthermore, the rapid, accurate detection of BA.5 in sewage demonstrates the feasibility of the PEC platform for sewage monitoring. In conclusion, this platform allows early detection and tracking of infectious disease outbreaks, providing timely data support for public health institutions to take appropriate prevention and control measures.

Determinants of diarrhoeal diseases among under-five children in Africa (2013-2023): a comprehensive systematic review highlighting geographic variances, socioeconomic influences, and environmental factors

BACKGROUND

Diarrhea diseases continue to present a significant threat to the well-being of children under the age of five in Africa, thereby contributing substantially to both morbidity and mortality rates. The period spanning between January 2013 and December 2023 has witnessed persistent challenges in the fight against these diseases, thereby necessitating a thorough investigation into the factors that determine their occurrence. It is important to note that the burden of diarrhea diseases is not evenly distributed across the continent, with residence, socioeconomic, and environmental factors playing pivotal roles in shaping the prevalence and incidence rates. Consequently, this systematic review aimed to consolidate and analyze the existing body of literature on the determinants of diarrhea diseases among children under the age of five in Africa between January 2013 and December 2023.

METHOD

The systematic review employed a rigorous methodological approach to examine the determinants of diarrhea diseases among children under the age of five in Africa between January 2013 and December 2023. A comprehensive search strategy was implemented, utilizing databases such as PubMed, Scopus, and Web of Science, and incorporating relevant keywords. The inclusion criteria focused on studies published within the specified timeframe, with a specific focus on the determinants of diarrhea disease among children under the age of five in Africa. The study selection process involved a two-stage screening, with independent reviewers evaluating titles, abstracts, and full texts to determine eligibility. The quality assessment, employing a standardized tool, ensured the inclusion of studies with robust methodologies. Data extraction encompassed key study details, including demographics, residence factors, socioeconomic influences, environmental variables, and intervention outcomes.

RESULTS

The search yielded a total of 12,580 articles across 25 African countries; however, only 97 of these articles met the inclusion criteria and were ultimately included in the systematic review. The systematic review revealed geographic and seasonal disparities in the prevalence of diarrhoeal diseases across different countries in Africa. Factors such as age-related vulnerabilities, gender disparities, maternal occupation, disposal of young children's stools, and economic status were identified as significant determinants of the prevalence of diarrhea disease.

CONCLUSION

This systematic review provides a comprehensive understanding of the determinants of diarrhea diseases among children under the age of five in Africa between January 2013 and December 2023. The nuanced analysis of residence variations, socioeconomic influences, environmental factors, and intervention outcomes underscores the complex nature of this issue. The findings highlight the necessity for region-specific and context-sensitive interventions to address the unique challenges faced by diverse communities. This review serves as a valuable resource for policymakers, healthcare professionals, and researchers, guiding the development of evidence-based strategies aimed at reducing the burden of diarrhea diseases and improving child health outcomes in Africa.

Inadequate sanitation in healthcare facilities: A comprehensive evaluation of toilets in major hospitals in Dhaka, Bangladesh

BACKGROUND

Lack of access to functional and hygienic toilets in healthcare facilities (HCFs) is a significant public health issue in low- and middle-income countries (LMICs), leading to the transmission of infectious diseases. Globally, there is a lack of studies characterising toilet conditions and estimating user-to-toilet ratios in large urban hospitals in LMICs. We conducted a cross-sectional study in 10-government and two-private hospitals to explore the availability, functionality, cleanliness, and user-to-toilet ratio in Dhaka, Bangladesh.

METHODS

From Aug-Dec 2022, we undertook infrastructure assessments of toilets in selected hospitals. We observed all toilets and recorded attributes of intended users, including sex, disability status, patient status (in-patient/out-patient/caregiver) and/or staff (doctor/nurse/cleaner/mixed-gender/shared). Toilet functionality was defined according to criteria used by the WHO/UNICEF Joint-Monitoring Programme in HCFs. Toilet cleanliness was assessed, considering visible feces on any surface, strong fecal odor, presence of flies, sputum, insects, and rodents, and solid waste.

RESULTS

Amongst 2875 toilets, 2459 (86%) were observed. Sixty-eight-percent of government hospital toilets and 92% of private hospital toilets were functional. Only 33% of toilets in government hospitals and 56% in private hospitals were clean. A high user-to-toilet ratio was observed in government hospitals' outpatients service (214:1) compared to inpatients service (17:1). User-to-toilet ratio was also high in private hospitals' outpatients service (94:1) compared to inpatients wards (19:1). Only 3% of toilets had bins for menstrual-pad disposal and <1% of toilets had facilities for disabled people.

CONCLUSION

A high percentage of unclean toilets coupled with high user-to-toilet ratio hinders the achievement of SDG by 2030 and risks poor infection-control. Increasing the number of usable, clean toilets in proportion to users is crucial. The findings suggest an urgent call for attention to ensure basic sanitation facilities in Dhaka's HCFs. The policy makers should allocate resources for adequate toilets, maintenance staff, cleanliness, along with strong leadership of the hospital administrators.

A review of latrine front-end characteristics associated with microbial infection risk; reveals a lack of pathogen density data

Unsafe sanitation accounts for an estimated 898,000 global deaths annually. The faecal pathogen transmission pathway is complex with several possible routes. Latrine front-end characteristics and usage behaviours are one key transmission pathway for microbial pathogens, however, there has not yet been a synthesis of the available research. This review aims to compare the microbial infection risks with latrine front-end components including any quantified microbial densities within the household latrines. This review was conducted with no restriction on the geographical location of the research. Of 118 studies reviewed, only ten (8%) have quantified the microbial density inside the household latrines compared to 109 (92%) measuring the infection risks. The reported risks were most frequent for specific bacterial (n = 34), and helminths infections (n = 32) compared to diarrhoea (n = 23), combined (n = 15), protozoan (n = 4), and viral (n = 4) infections. The infections risk decreased for using latrines lying at a higher position on the sanitation ladder (for example flush latrines) compared to those lying lower (for example pit latrines). The trend was similar for using floor materials that were easier to clean and less favourable for pathogen survival inside the latrines (for example, concrete as opposed to earth). Faecal coliforms were reported highest on the surface of the squat pan (743 CFU/cm2) of pour-flush latrines and helminths on earth floors of pit latrines (1.5 eggs and larvae per gram of soil). Irrespective of latrine type and its position on the sanitation ladder, a dirty latrine, evidenced by a visible lack of cleanliness, significantly increased the risk for all infections. This study recommends that effective microbial infection risk reduction in latrines can be gained efficiently by ensuring washable surfaces and consistent cleaning practices. Future studies should include more rigorous measurements of microbial densities in various latrine types incorporating the different front-end components and usage behaviours.

First report on the toxicity of SARS-CoV-2, alone and in combination with polyethylene microplastics in neotropical fish

The COVID-19 pandemic has caused unprecedented negative impacts in the modern era, including economic, social, and public health losses. On the other hand, the potential effects that the input of SARS-CoV-2 in the aquatic environment from sewage may represent on non-target organisms are not well known. In addition, it is not yet known whether the association of SARS-CoV-2 with other pollutants, such as microplastics (MPs), may further impact the aquatic biota. Thus, we aimed to evaluate the possible ecotoxicological effects of exposure of male adults Poecilia reticulata, for 15 days, to inactivated SARS-CoV-2 (0.742 pg/L; isolated SARS.CoV2/SP02.2020.HIAE.Br) and polyethylene MP (PE MPs) (7.1 × 10⁴ particles/L), alone and in combination, from multiple biomarkers. Our data suggest that exposure to SARS-CoV-2 induced behavioral changes (in the open field test), nephrotoxic effect (inferred by the increase in creatinine), hepatotoxic effect (inferred by the increase in bilirubin production), imbalance in the homeostasis of Fe, Ca, and Mg, as well as an anticholinesterase effect in the animals [marked by the reduction of acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) activity]. On the other hand, exposure to PE MPs induced a genotoxic effect (assessed by the comet assay), as well as an increase in enzyme activity alpha-amylase, alkaline phosphatase, and carboxylesterases. However, we did not show synergistic, antagonistic, or additive effects caused by the combined exposure of P. reticulata to SARS-CoV-2 and PE MPs. Principal component analysis (PCA) and values from the "Integrated Biomarker Response" index indicate that exposure to SARS-CoV-2 was determinant for a more prominent effect in the evaluated animals. Therefore, our study sheds light on the ecotoxicity of the new coronavirus in non-target organisms and ratifies the need for more attention to the impacts of COVID-19 on aquatic biota.

Toilet plume bioaerosols in health care and hospitality settings: A systematic review

BACKGROUND

The spread of some respiratory and gastro-intestinal infections has been linked to the exposure to infectious bioaerosols released after toilet flushing. This represents a health hazard and infection risk for immunocompromised patients, health workers and the public, particularly within the health care and hospitality settings. This systematic review provides current knowledge and identifies gaps in the evidence regarding toilet plume bioaerosols and the potential contributory role in spreading infections in health care and hospitality settings.

METHODS

The PRISMA guidelines were used. Searches were run in PubMed, Scopus, and Google Scholar from 1950 to 30th June 2021. Searches of global and regional reports and updates from relevant international and governmental organizations were also conducted.

RESULTS AND CONCLUSION

The search yielded 712 results, and 37 studies were finally selected for this review. There is a lack of national and international bioaerosol sampling and exposure standards for health care and hospitality settings. Toilet plume bioaerosols are complex in nature, thus, measured bioaerosol concentrations in these settings depend on many variables and may differ for every pathogen responsible for a particular infectious disease. The contact and airborne transmission risks posed by toilet plume bioaerosols also remain unquantified. They are an important pathway that can increase the exposure to enteric and airborne pathogens. Hence, quantitative risk assessment and related research are needed to investigate these transmission risks.

Spike in pollution to ignite the bursting of COVID-19 second wave is more dangerous than spike of SAR-CoV-2 under environmental ignorance in long term: a review

Specific areas in many countries such as Italy, India, China, Brazil, Germany and the USA have witnessed that air pollution increases the risk of COVID-19 severity as particulate matters transmit the virus SARS-CoV-2 and causes high expression of ACE2, the receptor for spike protein of the virus, especially under exposure to NO2, SO2 and NOx emissions. Wastewater-based epidemiology of COVID-19 is also noticed in many countries such as the Netherlands, the USA, Paris, France, Australia, Spain, Italy, Switzerland China, India and Hungary. Soil is also found to be contaminated by the RNA of SARS-CoV-2. Activities including defecation and urination by infected people contribute to the source for soil contamination, while release of wastewater containing cough, urine and stool of infected people from hospitals and home isolation contributes to the source of SARS-CoV-2 RNA in both water and soil. Detection of the virus early before the outbreak of the disease supports this fact. Based on this information, spike in pollution is found to be more dangerous in long-term than the spike protein of SARS-CoV-2. It is because the later one may be controlled in future within months or few years by vaccination and with specific drugs, but the former one provides base for many diseases including the current and any future pandemics. Although such predictions and the positive effects of SARS-CoV-2 on environment was already forecasted after the first wave of COVID-19, the learnt lesson as spotlight was not considered as one of the measures for which 2nd wave has quickly hit the world.

Municipal solid waste, an overlooked route of transmission for the severe acute respiratory syndrome coronavirus 2: a review

Municipal solid waste could potentially transmit human pathogens during the collection, transport, handling, and disposal of waste. Workers and residents living in the vicinity of municipal solid waste collection or disposal sites are particularly susceptible, especially unprotected workers and waste pickers. Recent evidence suggests that municipal solid waste-mediated transmission can spread the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to humans. Such risks, however, have received little attention from public health authorities so far and may present an under-investigated transmission route for SARS-CoV-2 and other infectious agents during pandemics. In this review, we provide a retrospective analysis of the challenges, practices, and policies on municipal solid waste management during the current pandemic, and scrutinize the recent case reports on the municipal solid waste-mediated transmission of the coronavirus disease 2019 (COVID-19). We found abrupt changes in quantity and composition of municipal solid wastes during the COVID-19. We detail pathways of exposure to SARS-CoV-2 and other pathogens carried on municipal solid wastes. We disclose evidence of pathogenic transmission by municipal solid waste to humans and animals. Assessments of current policies, gaps, and voluntary actions taken on municipal solid waste handling and disposal in the current pandemic are presented. We propose risk mitigation strategies and research priorities to alleviate the risk for humans and vectors exposed to municipal solid wastes.

Environmental contributions to the interactions of COVID-19 and asthma: A secondary publication and update

An outbreak of coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) started in Wuhan, Hubei Province, China and quickly spread around the world. Current evidence is contradictory on the association of asthma with COVID-19 and associated severe outcomes. Type 2 inflammation may reduce the risk for severe COVID-19. Whether asthma diagnosis may be a risk factor for severe COVID-19, especially for those with severe disease or non-allergic phenotypes, deserves further attention and clarification. In addition, COVID-19 does not appear to provoke asthma exacerbations, and asthma therapeutics should be continued for patients with exposure to COVID-19. Changes in the intensity of pollinization, an earlier start and extension of the pollinating season, and the increase in production and allergenicity of pollen are known direct effects that air pollution has on physical, chemical, and biological properties of the pollen grains. They are influenced and triggered by meteorological variables that could partially explain the effect on COVID-19. SARS-CoV-2 is capable of persisting in the environment and can be transported by bioaerosols which can further influence its transmission rate and seasonality. The COVID-19 pandemic has changed the behavior of adults and children globally. A general trend during the pandemic has been human isolation indoors due to school lockdowns and loss of job or implementation of virtual work at home. A consequence of this behavior change would presumably be changes in indoor allergen exposures and reduction of inhaled outdoor allergens. Therefore, lockdowns during the pandemic might have improved some specific allergies, while worsening others, depending on the housing conditions.

Prevalence, genetic diversity, antibiotic resistance and biofilm formation of Acinetobacter baumannii isolated from urban environments

AIM

Acinetobacter baumannii is a well-known nosocomial pathogen that has been isolated from different clinical sources. This pathogen also causes community-acquired infections, with mortality rates as high as 64%. The exact natural habitat of this bacterium is still unknown. In this study, we investigated the prevalence of A. baumannii in diverse soil and high-touch surface samples collected from a university campus, malls, parks, hypermarkets and produce markets, roundabout playground slides, and bank ATMs.

METHODS AND RESULTS

All obtained isolates were characterized for their antibiotic susceptibility, biofilm formation capacities, and were typed by multi-locus sequence analysis. A total of 63 A. baumannii isolates were recovered, along with 46 A. pittii and 8 A. nosocomialis isolates. Sequence typing revealed that 25 A. baumannii isolates are novel strains. Toilets and sink washing basins were the most contaminated surfaces, accounting for almost 50% of the recovered isolates. A number of A. baumannii (n=10), A. pittii (n=19) and A. nosocomialis (n=5) isolates were recovered from handles of shopping carts and baskets. The majority of isolates were strong biofilm formers and 4 exhibited a multi-drug resistant (MDR) phenotype.

CONCLUSIONS

Our study is the first to highlight community restrooms and shopping carts as potential reservoirs for pathogenic Acinetobacter species. Further studies are required to identify the reasons associated with the occurrence of A. baumannii inside restrooms. Proper disinfection of community environmental surfaces and spreading awareness about the importance of hand hygiene may prevent the dissemination of pathogenic bacteria within the community.

SIGNIFICANCE AND IMPACT OF STUDY

Serious gaps remain in our knowledge of how A. baumannii spreads to cause disease. This study will advance our understanding of how this pathogen spreads between healthcare and community environments. In addition, our findings will help healthcare decision makers implement better measures to control and limit further transmission of A. baumannii.

Multi-Feature Intelligent Oral English Error Correction Based on Few-Shot Learning Technology

The computer-aided language teaching system is maturing thanks to the advancement of few-shot learning technologies. In order to support teachers and increase students' learning efficiency, more computer-aided language teaching systems are being used in teaching and examinations. This study focuses on a multifeature fusion-based evaluation method for oral English learning, completely evaluating specific grammar, and assisting oral learners in improving their oral pronunciation skills. This study proposes an improved method based on HMM a posteriori probability scoring, in which the only standard reference model is no longer used as the basis for scoring and error determination, and instead, the average level of standard pronunciation in the entire corpus is introduced as another judgment basis, based on a preliminary study of speech recognition technology, scoring methods, and relevant theoretical knowledge of information feedback. This strategy can reduce the score limitation caused by standard pronunciation personal differences, lower the system's misjudgment rate in detecting pronunciation errors, and improve the usefulness of error correction information. An expert opinion database has been created based on the most prevalent forms of spoken pronunciation problems, which can successfully assist learners improve their spoken English level by combining the database's corrected information. Finally, this study proposes an artificial scoring system for spoken English that performs activities such as identification, scoring, error judgment, and correction opinion feedback, among others. Finally, it has been demonstrated through trials and tests that adding the average pronunciation level to the system improves the system's scoring performance and has a certain effect on increasing users' oral pronunciation level.

Can spike fragments of SARS-CoV-2 induce genomic instability and DNA damage in the guppy, Poecilia reticulate? An unexpected effect of the COVID-19 pandemic

The identification of SARS-CoV-2 particles in wastewater and freshwater ecosystems has raised concerns about its possible impacts on non-target aquatic organisms. In this particular, our knowledge of such impacts is still limited, and little attention has been given to this issue. Hence, in our study, we aimed to evaluate the possible induction of mutagenic (via micronucleus test) and genotoxic (via single cell gel electrophoresis assay, comet assay) effects in Poecilia reticulata adults exposed to fragments of the Spike protein of the new coronavirus at the level of 40 μg/L, denominated PSPD-2002. As a result, after 10 days of exposure, we have found that animals exposed to the peptides demonstrated an increase in the frequency of erythrocytic nuclear alteration (ENA) and all parameters assessed in the comet assay (length tail, %DNA in tail and Olive tail moment), suggesting that PSPD-2002 peptides were able to cause genomic instability and erythrocyte DNA damage. Besides, these effects were significantly correlated with the increase in lipid peroxidation processes [inferred by the high levels of malondialdehyde (MDA)] reported in the brain and liver of P. reticulata and with the reduction of the superoxide dismutase (SOD) and catalase (CAT) activity. Thus, our study constitutes a new insight and promising investigation into the toxicity associated with the dispersal of SARS-CoV-2 peptide fragments in freshwater environments.

Evaluating seasonal variations of fecal coliform colonization in Magallana hongkongensis and Crassostrea rhizophorae: A preliminary study of oyster quality grown in Hong Kong aquacultural farms

The objective of this research is to investigate the spatial and temporal patterns of bacteriological quality in raw oysters sampled from different aquacultural farms located in Aberdeen Typhoon Shelter, Carp Gates, Lau Fau Shan, Ma Wan, and Mui Wo in Hong Kong. Magallana hongkongensis and Crassostrea rhizophorae were collected and analyzed for fecal coliforms. Throughout the 13-month monitoring period, all samples had generally high bacterial loads, ranging from 1.4 × 10⁷ cfu/g to 8.9 × 10⁷ cfu/g and exceeded the guideline suggested by the HKSAR government (i.e. 700 MPN/100 g). Besides, a linear regression analysis showed that the amount of fecal coliforms in raw oysters had strong correlations (p < 0.05) to the monthly rainfall records throughout the monitoring period. Such findings illustrate the high loading of pathogenic microorganisms in the tissue of oysters which represent a potential threat of people contracting foodborne diseases.

Digital Twin Evaluation of Environment and Health of Public Toilet Ventilation Design Based on Building Information Modeling

Poor indoor air quality reduces the comfort experienced in the environment and can also harm our physical health. Mechanical ventilation design plays an important role in improving the indoor environment and the safety of public toilets. Therefore, in this study, we aimed to evaluate public toilet ventilation design schemes through a digital twin to determine the most effective scheme for reducing indoor pollutant concentrations. In this study, we used Autodesk Revit to create a digital twin BIM of different ventilation systems. We simulated the diffusion of pollutants in these models using computational fluid dynamics (CFD)-based methods, and we used DesignBuilder to simulate building energy consumption. From the perspective of architectural design, we determined measures important for reducing the concentration of air pollutants by increasing the number and volume of air exchanges and controlling the installation height of exhaust vents. The results show that the ventilation design of an all-air air conditioning system with an exhaust height of 400 mm can remarkably improve the indoor environmental health and ventilation efficiency of public toilets, while consuming 20.4% less energy and reducing carbon emissions by 30,681 kg CO2.

On the Critical Role of Human Feces and Public Toilets in the Transmission of COVID-19: Evidence from China

The surprising spread speed of the COVID-19 pandemic creates an urgent need for investigating the transmission chain or transmission pattern of COVID-19 beyond the traditional respiratory channels. This study therefore examines whether human feces and public toilets play a critical role in the transmission of COVID-19. First, it develops a theoretical model that simulates the transmission chain of COVID-19 through public restrooms. Second, it uses stabilized epidemic data from China to empirically examine this theory, conducting an empirical estimation using a two-stage least squares (2SLS) model with appropriate instrumental variables (IVs). This study confirms that the wastewater directly promotes the transmission of COVID-19 within a city. However, the role of garbage in this transmission chain is more indirect in the sense that garbage has a complex relationship with public toilets, and it promotes the transmission of COVID-19 within a city through interaction with public toilets and, hence, human feces. These findings have very strong policy implications in the sense that if we can somehow use the ratio of public toilets as a policy instrument, then we can find a way to minimize the total number of infections in a region. As shown in this study, pushing the ratio of public toilets (against open defecation) to the local population in a city to its optimal level would help to reduce the total infection in a region.

What is the risk of acquiring SARS-CoV-2 from the use of public toilets?

Public toilets and bathrooms may act as a contact hub point where community transmission of SARS-CoV-2 occurs between users. The mechanism of spread would arise through three mechanisms: inhalation of faecal and/or urinary aerosol from an individual shedding SARS-CoV-2; airborne transmission of respiratory aerosols between users face-to-face or during short periods after use; or from fomite transmission via frequent touch sites such as door handles, sink taps, lota or toilet roll dispenser. In this respect toilets could present a risk comparable with other high throughput enclosed spaces such as public transport and food retail outlets. They are often compact, inadequately ventilated, heavily used and subject to maintenance and cleaning issues. Factors such as these would compound the risks generated by toilet users incubating or symptomatic with SARS-CoV-2. Furthermore, toilets are important public infrastructure since they are vital for the maintenance of accessible, sustainable and comfortable urban spaces. Given the lack of studies on transmission through use of public toilets, comprehensive risk assessment relies upon the compilation of evidence gathered from parallel studies, including work performed in hospitals and prior work on related viruses. This narrative review examines the evidence suggestive of transmission risk through use of public toilets and concludes that such a risk cannot be lightly disregarded. A range of mitigating actions are suggested for both users of public toilets and those that are responsible for their design, maintenance and management.

A Global Overview of SARS-CoV-2 in Wastewater: Detection, Treatment, and Prevention

A novel coronavirus (SARS-CoV-2) causing corona virus disease 2019 (COVID-19) has attracted global attention due to its highly infectious and pathogenic properties. Most of current studies focus on aerosols released from infected individuals, but the presence of SARS-CoV-2 in wastewater also should be examined. In this review, we used bibliometrics to statistically evaluate the importance of water-related issues in the context of COVID-19. The results show that the levels and transmission possibilities of SARS-CoV-2 in wastewater are the main concerns, followed by potential secondary pollution by the intensive use of disinfectants, sludge disposal, and the personal safety of workers. The presence of SARS-CoV-2 in wastewater requires more attention during the COVID-19 pandemic. Thus, the most effective techniques, i.e., wastewater-based epidemiology and quantitative microbial risk assessment, for virus surveillance in wastewater are systematically analyzed. We further explicitly review and analyze the successful operation of a sewage treatment plant in Huoshenshan Hospital in China as an example and reference for other sewage treatment systems to properly ensure discharge safety and tackle the COVID-19 pandemic. This review offers deeper insight into the prevention and control of SARS-CoV-2 and similar viruses in the post-COVID-19 era from a wastewater perspective.

The viral phoenix: enhanced infectivity and immunity evasion of SARS-CoV-2 variants

SARS-CoV-2 pandemic continues with emergence of new variants of concerns. These variants are fueling the third and fourth waves of pandemic across many nations. Here we describe the new emerging variants of SARS-CoV-2 and why they have enhanced infectivity and possess the ability to evade immunity.

Pathophysiology of infection with SARS-CoV-2-What is known and what remains a mystery

Coronavirus disease 2019 (COVID‐19), caused by coronavirus severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), has caused extensive disruption and mortality since its recent emergence. Concomitantly, there has been a race to understand the virus and its pathophysiology. The clinical manifestations of COVID‐19 are manifold and not restricted to the respiratory tract. Extrapulmonary manifestations involving the gastrointestinal tract, hepatobiliary system, cardiovascular and renal systems have been widely reported. However, the pathophysiology of many of these manifestations is controversial with questionable support for direct viral invasion and an abundance of alternative explanations such as pre‐existing medical conditions and critical illness. Prior research on SARS‐Co‐V and NL63 was rapidly leveraged to identify angiotensin‐converting enzyme 2 (ACE2) receptor as the key cell surface receptor for SARS‐CoV‐2. The distribution of ACE2 has been used as a starting point for estimating vulnerability of various tissue types to SARS‐CoV‐2 infection. Sophisticated organoid and animal models have been used to demonstrate such infectivity of extrapulmonary tissues in vitro, but the clinical relevance of these findings remains uncertain. Clinical autopsy studies are typically small and inevitably biased towards patients with severe COVID‐19 and prolonged hospitalization. Technical issues such as delay between time of death and autopsy, use of inappropriate antibodies for paraffin‐embedded tissue sections and misinterpretation of cellular structures as virus particles on electron micrograph images are additional problems encountered in the extant literature. Given that SARS‐CoV‐2 is likely to circulate permanently in human populations, there is no doubt that further work is required to clarify the pathobiology of COVID‐19.

SARS-CoV-2: sewage surveillance as an early warning system and challenges in developing countries

Transmission of novel coronavirus (SARS-CoV-2) in humans happens either through airway exposure to respiratory droplets from an infected patient or by touching the virus contaminated surface or objects (fomites). Presence of SARS-CoV-2 in human feces and its passage to sewage system is an emerging concern for public health. Pieces of evidence of the occurrence of viral RNA in feces and municipal wastewater (sewage) systems have not only warned reinforcing the treatment facilities but also suggest that these systems can be monitored to get epidemiological data for checking trend of COVID-19 infection in the community. This review summarizes the occurrence and persistence of novel coronavirus in sewage with an emphasis on the possible water environment contamination. Monitoring of novel coronavirus (SARS-CoV-2) via sewage-based epidemiology could deliver promising information regarding rate of infection providing a valid and complementary tool for tracking and diagnosing COVID-19 across communities. Tracking the sewage systems could act as an early warning tool for alerting the public health authorities for necessary actions. Given the impracticality of testing every citizen with limited diagnostic resources, it is imperative that sewage-based epidemiology can be tested as an early warning system. The need for the development of robust sampling strategies and subsequent detection methodologies and challenges for developing countries are also discussed.

Water, Sanitation, and Hygiene Practices and Challenges during the COVID-19 Pandemic: A Cross-Sectional Study in Rural Odisha, India

Water, sanitation, and hygiene (WASH) practices emerged as a critical component to controlling and preventing the spread of the COVID-19 pandemic. We conducted 131 semistructured phone interviews with households in rural Odisha, India, to understand behavior changes made in WASH practices as a result of the pandemic and challenges that would prevent best practices. Interviews were conducted from May through July 2020 with 73 heads of household, 37 caregivers of children < 5 years old, and 21 members of village water and sanitation committees in villages with community-level piped water and high levels of latrine ownership. The majority of respondents (86%, N = 104) reported a change in their handwashing practice due to COVID-19, typically describing an increase in handwashing frequency, more thorough washing method, and/or use of soap. These improved handwashing practices remained in place a few months after the pandemic began and were often described as a new consistent practice after additional daily actions (such as returning home), suggesting new habit formation. Few participants (13%) reported barriers to handwashing. Some respondents also detailed improvements in other WASH behaviors, including village-level cleaning of water tanks and/or treatment of piped water (48% of villages), household water treatment and storage (17% of respondents), and household cleaning (41% of respondents). However, there was minimal change in latrine use and child feces management practices as a result of the pandemic. We provide detailed thematic summaries of qualitative responses to allow for richer insights into these WASH behavior changes during the pandemic. The results also highlight the importance of ensuring communities have adequate WASH infrastructure to enable the practice of safe behaviors and strengthen resilience during a large-scale health crisis.

Detection and disinfection of COVID-19 virus in wastewater

The coronavirus disease 2019, COVID-19, caused by the severe acute respiratory syndrome coronavirus 2, SARS-CoV-2, appears as a major pandemic having adverse impact on public health and economic activities. Since viral replication in human enterocytes results in its faecal shedding, wastewater surveillance is an ideal, non-invasive, cost-effective and an early warning epidemiological approach to detect the genetic material of SARS-CoV-2. Here, we review techniques for the detection of SARS-CoV-2 in municipal wastewater, and disinfectants used to control viral spread. For detection, concentration of ribonucleic acid involves ultrafiltration, ultracentrifugation and polyethylene glycol precipitation. Identification is done by reverse transcriptase amplification, nucleic acid sequence-based amplification, helicase dependent amplification, loop-mediated isothermal amplification, recombinase polymerase amplification, high throughput screening and biosensor assays. Disinfectants include ultraviolet radiations, ozone, chlorine dioxide, hypochlorites and hydrogen peroxide. Wastewater surveillance data indicates viral presence within longer detection window, and provides transmission dynamics earlier than classical methods. This is particularly relevant for pre-symptomatic and asymptomatic COVID-19 cases.

Water, sanitation, and hygiene practices and challenges during the COVID-19 pandemic: a cross-sectional study in rural Odisha, India

Water, sanitation, and hygiene (WASH) practices emerged as a critical component to controlling and preventing the spread of the COVID-19 pandemic. We conducted 131 semi-structured phone interviews with households in rural Odisha, India to understand behavior changes made in WASH practices as a result of the pandemic and challenges that would prevent best practices. Interviews were conducted from May-July 2020 with 73 heads of household, 37 caregivers of children less than five years old, and 21 members of village water and sanitation committees in villages with community-level piped water and high levels of latrine ownership. The majority of respondents (86%, N=104) reported a change in their handwashing practice due to COVID-19 or the related government lockdown, typically describing an increase in handwashing frequency, more thorough washing method, and/or use of soap. These improved handwashing practices remained in place a few months after the pandemic began and were often described as a new consistent practice after additional daily actions (such as returning home), suggesting new habit formation. Few participants (13%) reported barriers to handwashing. Some respondents also detailed improvements in other WASH behaviors including village-level cleaning of water tanks and/or treatment of piped water (48% of villages), household water treatment and storage (17% of respondents), and household cleaning (41% of respondents). However, there was minimal change in latrine use and child feces management practices as a result of the pandemic. We provide detailed thematic summaries of qualitative responses to allow for richer insights into these WASH behavior changes, or lack thereof, during the pandemic. The results also highlight the importance of ensuring communities have adequate WASH infrastructure to enable the practice of safe behaviors and strengthen resilience during a large-scale health crisis.

Role of indoor aerosols for COVID-19 viral transmission: a review

The relationship between outdoor atmospheric pollution by particulate matter and the morbidity and mortality of coronavirus disease 2019 (COVID-19) infections was recently disclosed, yet the role of indoor aerosols is poorly known . Since people spend most of their time indoor, indoor aerosols are closer to human occupants than outdoors, thus favoring airborne transmission of COVID-19. Therefore, here we review the characteristics of aerosol particles emitted from indoor sources, and how exposure to particles affects human respiratory infections and transport of airborne pathogens. We found that tobacco smoking, cooking, vacuum cleaning, laser printing, burning candles, mosquito coils and incenses generate large quantities of particles, mostly in the ultrafine range below 100 nm. These tiny particles stay airborne, are deposited in the deeper regions of human airways and are difficult to be removed by the respiratory system. As a consequence, adverse effects can be induced by inhaled aerosol particles via oxidative stress and inflammation. Early epidemiological evidence and animal studies have revealed the adverse effects of particle exposure in respiratory infections. In particular, inhaled particles can impair human respiratory systems and immune functions, and induce the upregulation of angiotensin-converting enzyme 2, thus inducing higher vulnerability to COVID-19 infection. Moreover, co-production of inflammation mediators by COVID-19 infection and particle exposure magnifies the cytokine storm and aggravates symptoms in patients. We also discuss the role of indoor aerosol particles as virus carriers. Although many hypotheses were proposed, there is still few knowledge on interactions between aerosol articles and virus-laden droplets or droplet nuclei.

Guidelines: Discharge Instructions for Covid-19 Patients

INTRODUCTION/OBJECTIVES

Clinicians treating COVID-19 patients face a major challenge in providing an effective relationship with patients who are discharged to return to home in order to optimize patient self-management after discharge. The purpose of these discharge instructions is to assist and provide guidance for physicians, nurses, and other health care personnel involved in discharging COVID-19 patients to home after encounters at hospitals, emergency departments, urgent care settings, and medical offices.

METHODS

A systematic literature-search of studies evaluating both symptoms and signs of COVID-19 was performed in order to establish specific optimal performance criteria in monitoring a patient's status with regard to disease safety. These optimal performance criteria parameters were considered with regard to the severity of morbidity and mortality. Strategies used to develop the discharge instructions included review of a broad spectrum of literature to develop the discharge criteria.

RESULTS

These guidelines are presented for patient education and should achieve the essential goals including: enabling patients to understand their medical situation, preventing complications, supporting patients by providing instructions, helping patients make more effective use of available health services, and managing patient stress by giving patients comfort through the knowledge of specific recommendations including how to respond to situations.

CONCLUSION

The COVID-19 pandemic requires clinicians to efficiently teach their patients self-management strategies and to provide a safe educated response to the patient and the surrounding community environment. The primary goal of the patient education discharge-instructions (PEDI) is to provide self-management strategies for preventing complications and disease transmission.

Advanced packaging for distribution and storage of COVID-19 vaccines: a review

The outbreak of the coronavirus disease 2019 global pandemic (COVID-19) has affected billions of lives, posing critical challenges to the healthcare system, vaccine manufacturers, packaging scientists, and daily public activity. Biotechnological advances have allowed to create rapidly vaccines, yet the success of an efficient immunization mainly depends on the safe and timely delivery of vaccines. In particular, packaging plays a crucial role in protecting, preserving, transporting, and distributing vaccines. Here, we review advanced packaging for distribution and storage of COVID-19 vaccines, with focus on innovative hybrid packaging materials, cyclic olefin polymers with nanolayer glass, and vials for vaccines. We present vaccine packaging, auto-disable syringes, stoppers, and closures. We discuss the chronology of the packaging system, and the labeling of the vaccine packages, with emphasis on bar codes, quick response codes, vaccine vial monitors, anti-counterfeiting and traceability measures.

How human thermal plume influences near-human transport of respiratory droplets and airborne particles: a review

With mounting evidence and notable cases of large clustered infections, airborne transmission via droplets and particles has been recently acknowledged as an effective mode of transmission for COVID-19. How droplets and aerosol particles disperse are being transported into the human breathing zone-the last few inches for airborne transmission to effectuate-remains a key question which has been widely overlooked. Human thermal plume refers to the constantly rising airflows around the boundary layer of human body due to persisting temperature gradients between the body surfaces and the ambient air. Ample evidence indicated that the thermal plume controls the dispersion and transport of aerosols in the human microenvironment. Given that in calm indoor environments most air inhaled by human comes from the boundary layer where thermal plume flows through constantly, the role of thermal plume needs to be scrutinized to predict the diffusion of droplets, aerosols and other airborne carriers of the novel coronavirus around the human body for prioritizing infection control strategies. Here, we assessed the potential influences of the thermal plume on the transmission of COVID-19 and other airborne pathogens by reviewing the most pertinent evidence and analyzing key variables in the formation of thermal plume in indoor environments, e.g., ambient temperature, human posture and type of clothing. Our reviewed evidence and data indicate that the human thermal plume should facilitate the airborne transmission of COVID-19 in enclosed spaces by elevating small droplets and airborne particles into the breathing zone from lower regions and ascending respiratory droplets from the sources into the upper atmosphere. By drawing attention to aerosol transport dynamics in the human microenvironment, these insights may be useful for understanding COVID-19 transmission in enclosed spaces, especially those intended for public use.

Advanced packaging for distribution and storage of COVID-19 vaccines: a review

The outbreak of the coronavirus disease 2019 global pandemic (COVID-19) has affected billions of lives, posing critical challenges to the healthcare system, vaccine manufacturers, packaging scientists, and daily public activity. Biotechnological advances have allowed to create rapidly vaccines, yet the success of an efficient immunization mainly depends on the safe and timely delivery of vaccines. In particular, packaging plays a crucial role in protecting, preserving, transporting, and distributing vaccines. Here, we review advanced packaging for distribution and storage of COVID-19 vaccines, with focus on innovative hybrid packaging materials, cyclic olefin polymers with nanolayer glass, and vials for vaccines. We present vaccine packaging, auto-disable syringes, stoppers, and closures. We discuss the chronology of the packaging system, and the labeling of the vaccine packages, with emphasis on bar codes, quick response codes, vaccine vial monitors, anti-counterfeiting and traceability measures.