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.

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.

A project to identify the best practices and health performance objectives for building construction and renovation.

The 2014-2018 National Prevention Plan (NPP), in order to promote a correct relationship between health and the environment, indicated, among the central objectives, the definition of guidelines to promote the building hygiene codes in an eco-compatible way, but also to develop specific skills on the subject of confined environments and residential construction in the operators of the Regional Health Services. The CCM2015 Project has therefore set itself the goal of taking stock of the best health practices available today in terms of sustainability and eco-compatibility in the buildings' construction and renovation actions. All this in order to define updated health performance targets to be made available to the competent Authorities, to adapt the current legislation at national, regional and local level, and finally to define the contents of a continuing education (training courses) capable to support operators in risk assessment related to the built environment and in the definition of effective preventive measures.

Housing and health: an overview.

Living environment, and especially dwellings, affect directly and indirectly health in several ways end represent one of the key social determinants of health. The relationship between health and housing has long been recognized and, in the last decades, researchers developed several conceptual models to put in relation the numerous housing factors able to impact on inhabitants' health. For some authors, factors linked to housing and neighborhood conditions that influence health, can be grouped into four broad categories: first considers the health impacts of not having a stable home (residential instability); second, the financial burdens resulting from high-cost housing (affordability); third, the health impacts of conditions inside the home (the housing' safety and quality); lastly, the health impacts of neighborhoods, including both the environmental and social characteristics of where people live (neighborhood). It is evident that the theme of "housing and health" nowadays needs to be assessed with a multidisciplinary approach, because of the complexity and wideness of its components. Moreover it is today clear that to guarantee good health standards it is indispensable to direct political and administrative choices to improve the overall conditions of the neighborhood and of the buildings, and, At the same time, to dispose of a clear and updated regulatory system, since key factor to ensure Public Health protection and social justice.

Housing problems in a changing society: regulation and training needs in Italy.

The paper focuses on the social, economic and environmental trends of recent years in Italy, highlighting the issue of housing emergency, both in quantitative and qualitative terms. What emerges are several shortages in housing especially in the suburbs of large cities, emphasizing the relevance of this issue in terms of health consequences and its priority for the definition of local policies. The authors underline that the availability of accessible and healthy housing is a human right, and a multisectoral responsibility, achievable only if a contribution is made by all relevant sectors including housing, environmental, social welfare, urban planning, building management and public health. The authors conclude by stressing the strategic role of training and illustrating a proposal addressed to all stakeholders, aiming to provide health evidences in terms of impact of housing hazards on health and to describe good building practices, helpful in order to obtain safe and healthy homes.

Towards an update of the Italian Ministerial Decree July 5th, 1975.

In recent years, the Scientific Community and the Public Health world, in general, have devoted increasing interest to housing conditions, which are considered, to date, one of the main environmental and social determinants of the population's health. In particular, the Scientific Community has identified and studied various indoor well-being factors (e.g. lighting, temperature, ventilation, air quality, etc.). Some of these factors have been regulated by laws and regulations at various levels: the availability of clear and updated health requirements dictated by the regulations is fundamental to effectively protect public health, especially in confined environments. In the present work, we propose a revision of the Italian Ministerial Decree of July 5th, 1975 titled Modificazioni alle istruzioni ministeriali 20 giugno 1896 relativamente all'altezza minima ed ai requisiti igienico sanitari principali dei locali d'abitazione (Modifications to the ministerial instructions of June 20th, 1896 regarding the minimum height and the main hygienic-sanitary requirements of living spaces) in order to update the definition of the essential elements that qualify a space as habitable from the hygienic-sanitary point of view, taking into account the evidence gathered from the technical and scientific literature on the requirements and contents of the Building Codes of the major European countries.

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.

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.

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.

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.

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.

Heating, ventilation and air conditioning (HVAC) system, microbial air contamination and surgical site infection in hip and knee arthroplasties: the GISIO-SItI Ischia study.

BACKGROUND: Recent studies have questioned the role of unidirectional airflow ventilation system in reducing surgical site infection (SSI) in prosthetic implant surgery. The aim of the ISChIA study ("Infezioni del Sito Chirurgico in Interventi di Artroprotesi" which means "Surgical site infections in arthroplasty surgery") was to evaluate, as a contribution to this debate, the association between heating, ventilation and air conditioning systems, microbial air contamination and surgical site infection in hip and knee arthroplasty. METHODS: The study was performed from March 2010 to February 2012 in 14 hospitals, for a total of 28 operating theatres: 16 were equipped with vertical unidirectional airflow ventilation (U-OTs), 6 with mixed airflow ventilation (M-OTs), 6 with turbulent airflow ventilation (T-OTs). Microbial air contamination in the operating theatre was evaluated by means of passive (Index of Microbial Air contamination, IMA) and active (Colony Forming Units per cubic metre, cfu/m3) sampling. SSI surveillance was carried out according to the Hospitals in Europe Link for Infection Control through Surveillance protocol. RESULTS: A total of 1,285 elective prosthesis procedures (61.1% hip and 38.9% knee) were included in the study. The results showed a wide variability of the air microbial contamination in operating theatres equipped with unidirectional airflow. The recommended values of ≤2 IMA and ≤10 cfu/m3 were exceeded, respectively, by 58.9% and 46.4% of samples from U-OTs and by 87.6% and 100% of samples from M-OTs. No significant difference was observed between SSI cumulative incidence in surgical procedures performed in U-OTs compared with those performed in T-OTs. A lower risk of SSI, even though not statistically significant, was shown in surgical procedures performed in U-OTs with a microbial air contamination within the recommended values (≤2 IMA and ≤10 cfu/m3) compared with those performed in U-OTs where these limits were exceeded, and compared with those performed in T-OTs with microbial air contamination within the recommended values for this type of OTs (≤25 IMA, ≤180 cfu/m3. CONCLUSION: ISChIA study did not show a protective effect of unidirectional airflow compared with turbulent airflow in arthroplasty surgery. However, the frequent exceeding of recommended air microbial contamination values in OTs equipped with unidirectional airflow, and the lower SSI risk in surgical procedures performed in compliant U-OTs compared with those performed in non-compliant U-OTs and with those performed in compliant T-OTs, suggest the need of further studies, which should consider air microbial contamination and other aspects of SSI prevention that may negate the potential benefits of the ventilation system; differences in intrinsic and extrinsic risk factors, medical treatment and surgical technique are also to be considered. Training interventions aimed at improving the behaviour of operators are essential.

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.

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.

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.

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.

Knowledge and training needs on built environment and indoor health of Italian public health residents: a national survey.

INTRODUCTION: The Working Group for Hygiene of Built Environment and the National Council of Residents of the Italian Society of Hygiene, Preventive Medicine and Public Health conducted a nation-wide survey to evaluate the knowledge and training needs on Built Environment and Indoor Health of Italian public health residents. RESULTS: The compliance was very high (52,4%), covering the totality of Italian postgraduate schools. The results underline a severe lack of theoretical formation and practical training, but also diffuse discrepancies across the country, and show a strong interest of residents on this topic. CONCLUSIONS: The authors propose to adopt a national core curriculum, and suggest some strategies to improve learning.

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.

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.

Health inequalities and inadequate housing: the case of exceptions to hygienic requirements for dwellings in Italy.

In the past decades, Italian hygienic requirements for dwellings have been modified by multiple derogations. Aim of the present work is to analyse the derogations introduced at a national, regional, and local level. The most important derogations were related to the habitable use of semi-basements and garrets, and building restoration. The paper also describes the regulations regarding indemnity for infringement of building abuses. The authors underline the need for more uniformity and clarity in the determination of health standards of dwellings, as well as for a simplification of the existing legislation.