Indoor air in healing environments

Cleaning products: Their chemistry, effects on indoor air quality, and implications for human health

The use of cleaning and disinfecting products both at work and at home increased during the COVID-19 pandemic. Those products often include surfactants, acids/bases, carcinogens such as chloroform, and endocrine-disrupting chemicals, such as cyclosiloxanes, phthalates, and synthetic fragrances, which may cause harmful health effects among professional cleaners as well as among people exposed at home or in their workplaces. The aim of this study was to synthesize the effects of the commonly used chemical, surface cleaning and disinfecting products on indoor air quality, focusing on chemical and particulate matter pollutants, exposure, and human health in residential and public buildings. We also provide a summary of recommendations to avoid harmful exposure and suggest future research directions. PubMed, Google Scholar, Scopus, and Web of Science (WoS) were used to search the literature. Analysis of the literature revealed that the use of cleaning products and disinfectants increase occupants' exposure to a variety of harmful chemical air contaminants and to particulate matter. Occupational exposure to cleaning and disinfectant products has been linked to an increased risk of asthma and rhinitis. Residential exposure to cleaning products has been shown to have an adverse effect on respiratory health, particularly on asthma onset, and on the occurrence of asthma(-like) symptoms among children and adults. Efforts to reduce occupants' exposure to cleaning chemicals will require lowering the content of hazardous substances in cleaning products and improving ventilation during and after cleaning. Experimentally examined, best cleaning practices as well as careful selection of cleaning products can minimize the burden of harmful air pollutant exposure indoors. In addition, indirect ways to reduce exposure include increasing people's awareness of the harmfulness of cleaning chemicals and of safe cleaning practices, as well as clear labelling of cleaning and disinfecting products.

Indoor Air Quality in Healthcare Units—A Systematic Literature Review Focusing Recent Research

The adequate assessment and management of indoor air quality in healthcare facilities is of utmost importance for patient safety and occupational health purposes. This study aims to identify the recent trends of research on the topic through a systematic literature review following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) methodology. A total of 171 articles published in the period 2015–2020 were selected and analyzed. Results show that there is a worldwide growing research interest in this subject, dispersed in a wide variety of scientific journals. A textometric analysis using the IRaMuTeQ software revealed four clusters of topics in the sampled articles: physicochemical pollutants, design and management of infrastructures, environmental control measures, and microbiological contamination. The studies focus mainly on hospital facilities, but there is also research interest in primary care centers and dental clinics. The majority of the analyzed articles (85%) report experimental data, with the most frequently measured parameters being related to environmental quality (temperature and relative humidity), microbiological load, CO2 and particulate matter. Non-compliance with the WHO guidelines for indoor air quality is frequently reported. This study provides an overview of the recent literature on this topic, identifying promising lines of research to improve indoor air quality in healthcare facilities.

A systematic review and meta-analysis of indoor bioaerosols in hospitals: The influence of heating, ventilation, and air conditioning

OBJECTIVES

To evaluate (1) the relationship between heating, ventilation, and air conditioning (HVAC) systems and bioaerosol concentrations in hospital rooms, and (2) the effectiveness of laminar air flow (LAF) and high efficiency particulate air (HEPA) according to the indoor bioaerosol concentrations.

METHODS

Databases of Embase, PubMed, Cochrane Library, MEDLINE, and Web of Science were searched from 1st January 2000 to 31st December 2020. Two reviewers independently extracted data and assessed the quality of the studies. The samples obtained from different areas of hospitals were grouped and described statistically. Furthermore, the meta-analysis of LAF and HEPA were performed using random-effects models. The methodological quality of the studies included in the meta-analysis was assessed using the checklist recommended by the Agency for Healthcare Research and Quality.

RESULTS

The mean CFU/m3 of the conventional HVAC rooms and enhanced HVAC rooms was lower than that of rooms without HVAC systems. Furthermore, the use of the HEPA filter reduced bacteria by 113.13 (95% CI: -197.89, -28.38) CFU/m3 and fungi by 6.53 (95% CI: -10.50, -2.55) CFU/m3. Meanwhile, the indoor bacterial concentration of LAF systems decreased by 40.05 (95% CI: -55.52, -24.58) CFU/m3 compared to that of conventional HVAC systems.

CONCLUSIONS

The HVAC systems in hospitals can effectively remove bioaerosols. Further, the use of HEPA filters is an effective option for areas that are under-ventilated and require additional protection. However, other components of the LAF system other than the HEPA filter are not conducive to removing airborne bacteria and fungi.

LIMITATION OF STUDY

Although our study analysed the overall trend of indoor bioaerosols, the conclusions cannot be extrapolated to rare, hard-to-culture, and highly pathogenic species, as well as species complexes. These species require specific culture conditions or different sampling requirements. Investigating the effects of HVAC systems on these species via conventional culture counting methods is challenging and further analysis that includes combining molecular identification methods is necessary.

STRENGTH OF THE STUDY

Our study was the first meta-analysis to evaluate the effect of HVAC systems on indoor bioaerosols through microbial incubation count. Our study demonstrated that HVAC systems could effectively reduce overall bioaerosol concentrations to maintain better indoor air quality. Moreover, our study provided further evidence that other components of the LAF system other than the HEPA filter are not conducive to removing airborne bacteria and fungi.

PRACTICAL IMPLICATION

Our research showed that HEPA filters are more effective at removing bioaerosols in HVAC systems than the current LAF system. Therefore, instead of opting for the more costly LAF system, a filter with a higher filtration rate would be a better choice for indoor environments that require higher air quality; this is valuable for operating room construction and maintenance budget allocation.

Indoor Air Quality Monitoring Systems Based on Internet of Things: A Systematic Review

Indoor air quality has been a matter of concern for the international scientific community. Public health experts, environmental governances, and industry experts are working to improve the overall health, comfort, and well-being of building occupants. Repeated exposure to pollutants in indoor environments is reported as one of the potential causes of several chronic health problems such as lung cancer, cardiovascular disease, and respiratory infections. Moreover, smart cities projects are promoting the use of real-time monitoring systems to detect unfavorable scenarios for enhanced living environments. The main objective of this work is to present a systematic review of the current state of the art on indoor air quality monitoring systems based on the Internet of Things. The document highlights design aspects for monitoring systems, including sensor types, microcontrollers, architecture, and connectivity along with implementation issues of the studies published in the previous five years (2015-2020). The main contribution of this paper is to present the synthesis of existing research, knowledge gaps, associated challenges, and future recommendations. The results show that 70%, 65%, and 27.5% of studies focused on monitoring thermal comfort parameters, CO₂, and PM levels, respectively. Additionally, there are 37.5% and 35% of systems based on Arduino and Raspberry Pi controllers. Only 22.5% of studies followed the calibration approach before system implementation, and 72.5% of systems claim energy efficiency.

Indoor Air Quality Monitoring Systems Based on Internet of Things: A Systematic Review

Indoor air quality has been a matter of concern for the international scientific community. Public health experts, environmental governances, and industry experts are working to improve the overall health, comfort, and well-being of building occupants. Repeated exposure to pollutants in indoor environments is reported as one of the potential causes of several chronic health problems such as lung cancer, cardiovascular disease, and respiratory infections. Moreover, smart cities projects are promoting the use of real-time monitoring systems to detect unfavorable scenarios for enhanced living environments. The main objective of this work is to present a systematic review of the current state of the art on indoor air quality monitoring systems based on the Internet of Things. The document highlights design aspects for monitoring systems, including sensor types, microcontrollers, architecture, and connectivity along with implementation issues of the studies published in the previous five years (2015-2020). The main contribution of this paper is to present the synthesis of existing research, knowledge gaps, associated challenges, and future recommendations. The results show that 70%, 65%, and 27.5% of studies focused on monitoring thermal comfort parameters, CO2, and PM levels, respectively. Additionally, there are 37.5% and 35% of systems based on Arduino and Raspberry Pi controllers. Only 22.5% of studies followed the calibration approach before system implementation, and 72.5% of systems claim energy efficiency.

How Can Design Features and Other Factors Affect the Indoor Air Quality in Inpatient Rooms? Check-Lists for the Design Phase, Daily Procedures and Maintenance Activities for Reducing the Air Concentrations of Chemical Pollution

Indoor Air Quality (IAQ) is one of main topics of Public Health on which international institutions and countries are taking action. With regards to healing architectures, several studies have reported data analysis and case studies to improve users' health (patients, and medical and administrative staffs), but there are not enough regarding volatile organic compounds (VOCs). Regarding chemical pollution of indoor air, the Scientific Community has highlighted that there are several factors that affect the IAQ, in particular the design and management, and energetic efficiency, of inpatient wards. Several stakeholders, from the designers to the managers, are responsible for the indoor air in healing environments. Supported by analysis of the State of the Art and the main factors that influence the heterogeneous scenario of inpatient wards, the paper presents three check-lists, designed for supporting the stakeholders during the design phase, or for the daily procedures and maintenance activities, for pre-assessment of factors that affect chemical pollution, and for the definition of strategies to be applied. In fact, in such environments IAQ assumes a particular meaning and importance, both for the vulnerability of the patients and for the long time spent by the sanitary staff. The multidisciplinary approach emphasizes the continuous need for interdisciplinary knowledge and skills aimed at finding solutions able to protect users' health status (including patients, workers and visitors), especially in the field of the indoor air issue.

Indoor Air Quality: A Focus on the European Legislation and State-of-the-Art Research in Italy

The World Health Organization (WHO) has always stressed the importance of indoor air quality (IAQ) and the potential danger of pollutants emitted from indoor sources; thus, it has become one of the main determinants for health. In recent years, reference documents and guidelines have been produced on many pollutants in order to: i) decrease their impact on human health (as well as the number of pollutants present in indoor environments), and ii) regulate the relevant levels of chemicals that can be emitted from the various materials. The aim of this paper is to discuss and compare the different legislations present in the European Union (EU). Furthermore, a focus of this paper will be dedicated at Italian legislation, where there is currently no specific reference to IAQ. Although initiatives in the pre-regulatory sector have multiplied, a comprehensive and integrated policy on the issue is lacking. Pending framework law for indoor air quality, which takes into account WHO indications, the National Study Group (GdS) on Indoor Air Pollution by the Italian Institute of Health (IIS) is committed to providing shared technical-scientific documents in order to allow actions harmonized at a national level. An outlook of the main Italian papers published during these last five years will be reported and discussed.

The Relevance of Indoor Air Quality in Hospital Settings: From an Exclusively Biological Issue to a Global Approach in the Italian Context

In the context of the architectures for health, it is an utmost priority to operate a regular and continuous updating of quality, efficacy, and efficiency’s processes. In fact, health promotion and prevention take place through a proper management and design of healing spaces, in particular with regard to the most sensitive users. In recent decades, there has been increasing attention to indoor air quality in healthcare facilities. Nowadays, this issue must involve the implementation of a series of appropriate interventions, with a global approach of prevention and reduction of risk factors on users’ health, which allows, in addition to a correct management of hospital settings, the realization of concrete actions. To date, in Italy, despite the indoor air being taken in consideration in numerous activities and studies aimed at understanding both building hygiene and environmental aspects, the greatest difficulty is strongly related to the absence of an integrated national policy. The scope of the paper is to underline the relevance of indoor air quality in hospital settings, highlighting the need of procedures, protocols, and tools for strengthening and improving interventions for health prevention, protection, and promotion of users.

Chemical Pollution in Healing Spaces: The Decalogue of the Best Practices for Adequate Indoor Air Quality in Inpatient Rooms

Indoor air quality (IAQ) is one of the main topics in which governments are focusing. In healthcare facilities, several studies have reported data analysis and case studies to improve users' health. Nowadays, although many studies have been conducted related to the biological and physical risks, the chemical risks have been less investigated and only in some specific functional areas of the hospitals. Starting from some systematic reviews and research works, this paper aims to list the best healthy practices for an adequate IAQ in inpatient wards. In particular, the decalogue lists the strategies related to chemical pollution, starting from design and management, with a focus on (a) localization of hospitals and inpatient rooms, (b) hospital room, (c) microclimatic parameters, (d) ventilation systems, (e) materials and finishing, (f) furniture and equipment, (g) cleaning products and activities, (h) maintenance and (i) management activities, and (l) users and workers. The multidisciplinary approach emphasizes the need for interdisciplinary knowledge and skills aimed to find solutions able to protect users' health status. The design and management decision-making, ranging from the adequate choices of construction site and hospital exposure, finishing materials, cleaning and maintenance activities, etc., which can affect the IAQ must be carried out based on scientific research and data analysis.

Healthy and Sustainable Hospital Evaluation—A Review of POE Tools for Hospital Assessment in an Evidence-Based Design Framework

Hospitals are complex, high-performance systems that demand continuous quality improvement. Several instruments evaluate the organizational or clinical qualities but very few focus on the built environment. The purpose of this paper is to compare and review the recent tools able to assess the hospital built environment and test how they measure health, sustainability, or both through Post Occupancy Evaluation (POE). A literature review has been conducted in the field of hospital quality assessment and 13 POE instruments have been included and analyzed through Ulrich’s Evidence-Based Design (EBD) framework. The percentage and the content of health or sustainability-related criteria have been compared and further discussed. Health related criteria the most recent tools are used three times more than in the tools developed in the nineties. The most used EBD criteria are safety enhancement (n = 131; 14%) and visual environment (n = 119; 13%). Although sustainability remains a relevant issue, today, growing attention is dedicated to the impact of built environment on occupant’s health. Further investigation is needed to understand the effectiveness of those instruments in practice.

Indoor Air Quality in Inpatient Environments: A Systematic Review on Factors that Influence Chemical Pollution in Inpatient Wards

Introduction

Indoor air quality is one the main issues in which governments are focusing. In healing spaces, several research studies are reporting a growing number of data analysis and research works in order to guarantee and prevent health of users and workers. Currently the main investigations are about biological and physical risks; otherwise chemical ones are less investigated. Several countries are carrying out indoor air quality monitoring in those professional workplaces in which chemicals are used but also in some typically indoor (generic) spaces for the building hygiene assessment. The indoor air is affected by several factors that currently are analyzed punctually, without a whole scenario of all the variable performances. The authors have done a systematic review on the current state of the art and knowledge related to chemical pollution in healing spaces and the emerging strategies, supported by scientific literature, for healthy inpatient rooms and their indoor air.

Methodology

The systematic review has been done through the analysis of papers from SCOPUS, DOAJ, and PubMed databases. The survey sample considered 483 scientific articles, between 1989 and 2017, and starting the systematic reading and analysis of the abstracts, only 187 scientific papers were selected, and only 96 were accessible.

Discussion

Since scientific literature reports very different outputs and results, the resulting work from the survey is divided into specific fields of interest related to construction and finishing materials, installations, components, ventilation systems, processes, etc. Starting from the systematic reading, the paper classifies the factors of indoor air in four macroareas: outdoor air and microclimatic factors (temperature, relative humidity, air velocity, air change, etc.); management activities (management and maintenance activities, ventilation systems, HVAC, cleaning and disinfectant activities, etc.); design factors (room dimensions, furniture, finishing materials, etc.); and human presence and medical activities (users' presence, their health status, and medical activities carried out in inpatient rooms).

Conclusion

The systematic review gives rise to a broad scenario on the existing knowledge regarding the indoor air pollution, design, and management strategies for healthy spaces and several emerging topics. Although the aim of the investigation is strictly related to chemical pollution, several considerations from the biological point of view have been listed. The systematic review, supported by the existing scientific literature, becomes a starting point for considering the importance of the topic and to stimulate the knowledge around this field of interest for improving studies, analysis, and simulations.