The role of Environmental Health in preventing antimicrobial resistance in low- and middle-income countries.

Antimicrobial resistance (AMR) is increasingly becoming a threat to global public health, not least in low- and middle-income countries (LMICs) where it is contributing to longer treatment for illnesses, use of higher generation drugs, more expenditure on antimicrobials, and increased deaths attributed to what should be treatable diseases. Some of the known causes of AMR include misuse and overuse of antimicrobials in both humans and animals, unnecessary use of antimicrobials in animals as growth promoters, and lack of awareness among the public on how to protect antimicrobials. As a result, resistant organisms are circulating in the wider environment, and there is a need to consider the One Health approach to minimise the continuing development of AMR. Environmental Health, specifically water, sanitation and hygiene (WASH), waste management, and food hygiene and safety, are key components of One Health needed to prevent the spread of antimicrobial-resistant microorganisms particularly in LMICs and reduce the AMR threat to global public health. The key Environmental Health practices in the prevention of AMR include: (1) adequate WASH through access and consumption of safe water; suitable containment, treatment and disposal of human excreta and other wastewater including from health facilities; good personal hygiene practices such as washing hands with soap at critical times to prevent the spread of resistant microorganisms, and contraction of illnesses which may require antimicrobial treatment; (2) proper disposal of solid waste, including the disposal of unused and expired antimicrobials to prevent their unnecessary exposure to microorganisms in the environment; and (3) ensuring proper food hygiene and safety practices, such as sale and consumption of animal products in which adequate antimicrobial withdrawal periods have been observed, and growing vegetables on unpolluted soil. Environmental Health is therefore crucial in the prevention of infectious diseases that would require antimicrobials, reducing the spread of resistant organisms, and exposure to antimicrobial residues in LMICs. Working with other professionals in One Health, Environmental Health Practitioners have a key role in reducing the spread of AMR including health education and promotion, surveillance, enforcement of legislation, and research.

Health Care Environmental Hygiene: New Insights and Centers for Disease Control and Prevention Guidance.

Recent research has significantly clarified the impact of optimizing patient-zone environmental hygiene. New insights into the environmental microbial epidemiology of many hospital-associated pathogens, especially Clostridioides difficile, have clarified and quantified the role of ongoing occult pathogen transmission from the near-patient environment. The recent development of safe, broadly effective surface chemical disinfectants has led to new opportunities to broadly enhance environmental hygiene in all health care settings. The Centers for Disease Control and Prevention has recently developed a detailed guidance to assist all health care settings in implementing optimized programs to mitigate health care-associated pathogen transmission from the near-patient surfaces.

Regulatory landscape of nanotechnology and nanoplastics from a global perspective.

Nanotechnology and more particularly nanotechnology-based products and materials have provided a huge potential for novel solutions to many of the current challenges society is facing. However, nanotechnology is also an area of product innovation that is sometimes developing faster than regulatory frameworks. This is due to the high complexity of some nanomaterials, the lack of a globally harmonised regulatory definition and the different scopes of regulation at a global level. Research organisations and regulatory bodies have spent many efforts in the last two decades to cope with these challenges. Although there has been a significant advancement related to analytical approaches for labelling purposes as well as to the development of suitable test guidelines for nanomaterials and their safety assessment, there is a still a need for greater global collaboration and consensus in the regulatory field. Furthermore, with growing societal concerns on plastic litter and tiny debris produced by degradation of littered plastic objects, the impact of micro- and nanoplastics on humans and the environment is an emerging issue. Despite increasing research and initial regulatory discussions on micro- and nanoplastics, there are still knowledge gaps and thus an urgent need for action. As nanoplastics can be classified as a specific type of incidental nanomaterials, current and future scientific investigations should take into account the existing profound knowledge on nanotechnology/nanomaterials when discussing issues around nanoplastics. This review was conceived at the 2019 Global Summit on Regulatory Sciences that took place in Stresa, Italy, on 24-26 September 2019 (GSRS 2019) and which was co-organised by the Global Coalition for Regulatory Science Research (GCRSR) and the European Commission's (EC) Joint Research Centre (JRC). The GCRSR consists of regulatory bodies from various countries around the globe including EU bodies. The 2019 Global Summit provided an excellent platform to exchange the latest information on activities carried out by regulatory bodies with a focus on the application of nanotechnology in the agriculture/food sector, on nanoplastics and on nanomedicines, including taking stock and promoting further collaboration. Recently, the topic of micro- and nanoplastics has become a new focus of the GCRSR. Besides discussing the challenges and needs, some future directions on how new tools and methodologies can improve the regulatory science were elaborated by summarising a significant portion of discussions during the summit. It has been revealed that there are still some uncertainties and knowledge gaps with regard to physicochemical properties, environmental behaviour and toxicological effects, especially as testing described in the dossiers is often done early in the product development process, and the material in the final product may behave differently. The harmonisation of methodologies for quantification and risk assessment of nanomaterials and micro/nanoplastics, the documentation of regulatory science studies and the need for sharing databases were highlighted as important aspects to look at.

Respiratory Protection in a Time of Crisis: NIOSH Testing of International Respiratory Protective Devices for Emergency Use.

National Institute for Occupational Safety and Health (NIOSH)-approved respirators are required by the Occupational Safety and Health Administration (OSHA) when personal respiratory protection is used in US occupational settings. During the COVID-19 pandemic, the demand for NIOSH-approved N95 filtering facepiece respirators overwhelmed the available supply. To supplement the national inventory of N95 respirators, contingency and crisis capacity strategies were implemented and incorporated a component that endorsed the use of non-NIOSH-approved respiratory protective devices that conformed to select international standards. The development and execution of this strategy required the collaborative effort of numerous agencies. The Food and Drug Administration temporarily authorized non-NIOSH-approved international respiratory protective devices through an emergency use authorization, OSHA relaxed their enforcement guidance concerning their use in US workplaces, and NIOSH initiated a supplemental performance assessment process to verify the quality of international devices. NIOSH testing revealed that many of the non-NIOSH-approved respiratory protective devices had filtration efficiencies below 95% and substantial inconsistencies in filtration performance. This article reports the results of the NIOSH testing to date and discusses how it has contributed to continuous improvement of the crisis strategy of temporarily permitting the use of non-NIOSH-approved respirators in US occupational settings during the COVID-19 pandemic.

What is necessary for next-generation atmospheric environmental standards? Recent research trends for PM2.5 -bound polycyclic aromatic hydrocarbons and their derivatives.

The air pollution associated with PM2.5 kills 7 million people every year in the world, especially threatening the health of children in developing countries. However, the current air quality standards depend mainly on particle size. PM2.5 contains many carcinogenic/mutagenic polycyclic aromatic hydrocarbons (PAHs) and their derivatives such as nitropolycyclic aromatic hydrocarbons and oxygenated PAHs. Among them, environmental standards and guidelines have been set for benzo[a]pyrene by few countries and international organizations. Recent research reports showed that these pollutants are linked to diseases other than lungs, and new methods have been developed for determining trace levels of not only PAHs but also their derivatives. It is time to think about the next-generation environmental standards. This article aims to (a) describe recent studies on the health effects of PAHs and their derivatives other than cancer, (b) describe new analytical methods for PAH derivatives, and (c) discuss the targets for the next-generation standards.

The role of Environmental Health in preventing antimicrobial resistance in low- and middle-income countries

Antimicrobial resistance (AMR) is increasingly becoming a threat to global public health, not least in low- and middle-income countries (LMICs) where it is contributing to longer treatment for illnesses, use of higher generation drugs, more expenditure on antimicrobials, and increased deaths attributed to what should be treatable diseases. Some of the known causes of AMR include misuse and overuse of antimicrobials in both humans and animals, unnecessary use of antimicrobials in animals as growth promoters, and lack of awareness among the public on how to protect antimicrobials. As a result, resistant organisms are circulating in the wider environment, and there is a need to consider the One Health approach to minimise the continuing development of AMR. Environmental Health, specifically water, sanitation and hygiene (WASH), waste management, and food hygiene and safety, are key components of One Health needed to prevent the spread of antimicrobial-resistant microorganisms particularly in LMICs and reduce the AMR threat to global public health. The key Environmental Health practices in the prevention of AMR include: (1) adequate WASH through access and consumption of safe water; suitable containment, treatment and disposal of human excreta and other wastewater including from health facilities; good personal hygiene practices such as washing hands with soap at critical times to prevent the spread of resistant microorganisms, and contraction of illnesses which may require antimicrobial treatment; (2) proper disposal of solid waste, including the disposal of unused and expired antimicrobials to prevent their unnecessary exposure to microorganisms in the environment; and (3) ensuring proper food hygiene and safety practices, such as sale and consumption of animal products in which adequate antimicrobial withdrawal periods have been observed, and growing vegetables on unpolluted soil. Environmental Health is therefore crucial in the prevention of infectious diseases that would require antimicrobials, reducing the spread of resistant organisms, and exposure to antimicrobial residues in LMICs. Working with other professionals in One Health, Environmental Health Practitioners have a key role in reducing the spread of AMR including health education and promotion, surveillance, enforcement of legislation, and research.

COVID-19​ and safe indoor spaces live Q&A with Maria Neira and Luca Fontana. Ask WHO​ 22 Sept. 2020

#AskWHO​ series: This was the live discussion about the COVID-19 pandemic of 16 September 2020 with Dr Mike Ryan, Executive Director of WHO Health Emergencies Programme, and Dr Maria Van Kerkhove, WHO Technical Lead on COVID-19. Questions from the audience were taken.

Need for global core competencies in Child Health and the Environment: a Canadian perspective.

Children are the planet's most valuable resource. Mortality rates and longevity in children are improving; however, morbidity related to early-life exposures is increasing and with it health spending. A focus on identifying and addressing environmental components related to not only chronic childhood illnesses but also major adult mortalities would help contain current healthcare budgets. Child Health and the Environment (CHE) is an emerging discipline dedicated to managing early-life exposures (prenatal and childhood) on health outcomes throughout life. In Canada, as well as around the world, recognition of this area is growing, but progress has been slow and training of physicians is lacking. The WHO works closely with the Children's Environmental Health Clinic in Canada as well as collaborating centres around the world to build awareness of environmental health issues and promote improved care of children. Core competencies in CHE for physicians would provide an important step forward.

Recomendaciones para medidas de salud pública ambiental durante la sequía y la conservación de agua, 11 de mayo del 2020 / Recommendations for Environmental Public Health Measures during Drought and Water Conservation, 11 May 2020

Proporcionar acceso universal a las estaciones públicas de higiene de manos, con indicaciones precisas para su uso correcto. •Garantizar el suministro continuo de agua segura en las instalaciones de salud. •Asegurar que las instalaciones de atención a largo plazo y los espacios comunitarios cerrados tengan un suministro continuo de agua segura. •Asegurar el acceso de agua segura a no más de 500 metros de la residencia. •Abogar para el acceso continuo de agua segura para toda la población. •Instalar tanques de almacenamiento temporales en áreas desatendidas y donde haya un servicio interrumpido, con niveles de cloro residual de 0,5 mg/L. •Asegurar que los tanques de agua y los camiones cisterna tengan un nivel de cloro residual de 0,5-1 mg/L. •Asegurar que el nivel de cloro residual en todo el sistema de suministro y en el punto de uso es de 0,5 mg/L. •Fortalecer las acciones de vigilancia de la calidad del agua, especialmente en las zonas más afectadas. •Promover el almacenamiento seguro de agua en los hogares, como tanques elevados con tapas y grifos. •Promover tecnologías de bajo costo para garantizar la calidad del agua, como los filtros de agua domésticos. •Realizar la coordinación del sector salud, con el sector de agua y otros sectores relevantes para definir e implementar las intervenciones. •Abogar por la participación intersectorial (por ejemplo, sector del agua, agricultura) en los comités de emergencia y desastre de los paises. •Reparar las tuberías con fugas. •Establecer una prohibición sobre el uso de mangueras. • Recomendar el uso de sistemas de inodoros de bajo flujo (por diseño o modernizados) en áreas propensas a la sequía. •Realizar intervenciones de prevención que hayan demostrado ser efectivas contra el SARS-COV-2.

This technical note contains recommendations for the public sector, the community, and health establishments to make rational use of water in conditions of low water availability due to drought.

Recomendaciones para la gestión de residuos sólidos, 11 de mayo del 2020 / Recommendations for the Management of Solid Waste, 11 May 2020 / Recomendações para o gerenciamento de resíduos sólidos, 11 de maio de 2020

Manejar residuos sólidos correctamente permite minimizar posibles impactos secundarios sobre la salud y el ambiente.

This technical note presents recommendations for handling solid waste correctly to minimize possible secondary impacts on health and the environment. The note covers safe management measures for personnel, transportation of common waste, final disposal services of waste, special considerations for the handling of waste from health facilities to be treated outside the facility, and waste management in homes.

Medidas de gestão: segura para os funcionários • Fornecer a toda a equipe operacional os equipamentos de proteção individual (EPIs) adequados para as suas tarefas (máscaras, macacão/bata, touca, luvas e botas). • Capacitar toda a equipe operacional e administrativa sobre as medidas de proteção individual e os riscos. • Solicitar à equipe que trabalha com manuseio de resíduos que use os EPIs em todas as etapas (coleta, transporte e disposição final). • Garantir a disponibilidade gratuita de locais para lavar as mãos com água e sabão. • Ao final do expediente, lavar as mãos com as luvas calçadas. Em seguida, colocar as luvas em um recipiente com uma solução de hipoclorito de sódio a 0,1%, seguindo as instruções da tabela abaixo, durante 1 minuto. Enxaguar e deixar secar para usá-las no dia seguinte. Depois, lavar as mãos. • Lavar e desinfetar os óculos de proteção com uma solução de hipoclorito de sódio a 0,1%, de acordo com as instruções da tabela abaixo. • Usar as máscaras de proteção conforme as normas nacionais. • Proibir os funcionários de abrirem os sacos de resíduos. • Manter uma distância de 2 m entre as equipes de pesagem, vigilância e os motoristas, mantendo o uso dos EPIs. • Alimentação deve ser realizada somente em áreas preestabelecidas, longe dos resíduos.

Health impacts of bushfire smoke exposure in Australia.

Smoke exposure from bushfires, such as those experienced in Australia during 2019-2020, can reach levels up to 10 times those deemed hazardous. Short-term and extended exposure to high levels of air pollution can be associated with adverse health effects, although the most recent fires have brought into sharp focus that several important knowledge gaps remain. In this article, we briefly identify and discuss the existing Australian evidence base and make suggestions for future research.

Impact of an integrated nutrition, health, water sanitation and hygiene, psychosocial care and support intervention package delivered during the pre- and peri-conception period and/or during pregnancy and early childhood on linear growth of infants in the first two years of life, birth outcomes and nutritional status of mothers: study protocol of a factorial, individually randomized controlled trial in India.

BACKGROUND: The period from conception to two years of life denotes a critical window of opportunity for promoting optimal growth and development of children. Poor nutrition and health in women of reproductive age and during pregnancy can negatively impact birth outcomes and subsequent infant survival, health and growth. Studies to improve birth outcomes and to achieve optimal growth and development in young children have usually tested the effect of standalone interventions in pregnancy and/or the postnatal period. It is not clearly known whether evidence-based interventions in the different domains such as health, nutrition, water sanitation and hygiene (WASH) and psychosocial care, when delivered together have a synergistic effect. Further, the effect of delivery of an intervention package in the pre and peri-conception period is not fully understood. This study was conceived with an aim to understand the impact of an integrated intervention package, delivered across the pre and peri-conception period, through pregnancy and till 24 months of child age on birth outcomes, growth and development in children. METHODS: An individually randomized controlled trial with factorial design is being conducted in urban and peri-urban low- to mid-socioeconomic neighbourhoods in South Delhi, India. 13,500 married women aged 18 to 30 years will be enrolled and randomized to receive either the pre and peri-conception intervention package or routine care (first randomization). Interventions will be delivered until women are confirmed to be pregnant or complete 18 months of follow up. Once pregnancy is confirmed, women are randomized again (second randomization) to receive either the intervention package for pregnancy and postnatal period or to routine care. Newborns will be followed up till 24 months of age. The interventions are delivered through different study teams. Outcome data are collected by an independent outcome ascertainment team. DISCUSSION: This study will demonstrate the improvement that can be achieved when key factors known to limit child growth and development are addressed together, throughout the continuum from pre and peri-conception until early childhood. The findings will increase our scientific understanding and provide guidance to nutrition programs in low- and middle-income settings. TRIAL REGISTRATION: Clinical Trial Registry - India #CTRI/2017/06/008908; Registered 23 June 2017, http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=19339&EncHid=&userName=society%20for%20applied%20studies.

Energy access in Malawian healthcare facilities: consequences for health service delivery and environmental health conditions.

Many healthcare facilities (HCFs) in low-income countries experience unreliable connectivity to energy sources, which adversely impacts the quality of health service delivery and provision of adequate environmental health services. This assessment explores the status and consequences of energy access through interviews and surveys with administrators and healthcare workers from 44 HCFs (central hospitals, district hospitals, health centres and health posts) in Malawi. Most HCFs are connected to the electrical grid but experience weekly power interruptions averaging 10 h; less than one-third of facilities have a functional back-up source. Inadequate energy availability is associated with irregular water supply and poor medical equipment sterilization; it adversely affects provider safety and contributes to poor lighting and working conditions. Some challenges, such as poor availability and maintenance of back-up energy sources, disproportionately affect smaller HCFs. Policymakers, health system actors and third-party organizations seeking to improve energy access and quality of care in Malawi and similar settings should address these challenges in a way that prioritizes the specific needs of different facility types.

An ecological framework for improving child and adolescent health.

The rise in non-communicable disease as a principal cause of premature mortality and a continuing failure to address health inequalities requires a critical examination of prevailing paradigms in health. In this paper, we offer ecology as an alternative way to view health need and as a guide to action to enhance human health and model a healthy economy. After describing the shortcomings of the prevailing biophysical approach to health, we describe an ecological approach to health that brings to the forefront social and environmental determinants and empowers health workers together with their communities to achieve a health-affirming society and economy.

Environmental, Nutritional, and Socioeconomic Determinants of IBD Incidence: A Global Ecological Study.

BACKGROUND AND AIMS: The wide variation in inflammatory bowel disease [IBD] incidence across countries entails an opportunity to recognise global disease determinants and hypothesise preventive policies. METHODS: We fitted multivariable models to identify putative environmental, nutritional, and socioeconomic determinants associated with the incidence of IBD (i.e. ulcerative colitis [UC] and Crohn's disease [CD]). We used the latest available country-specific incidence rates, and aggregate data for 20 determinants, from over 50 countries accounting for more than half of the global population. We presented the associations with exponentiated beta coefficients (exp[ß]) indicating the relative increase of disease incidence per unit increase in the predictor variables. RESULTS: Country-specific incidence estimates demonstrate wide variability across the world, with a median of 4.8 new UC cases (interquartile range [IQR] 2.4-9.3), and 3.5 new CD cases [IQR 0.8-5.7] per 100 000 population per year. Latitude (exp[ß] 1.05, 95% confidence interval [CI] 1.04‒1.06, per degree increase), prevalence of obesity [1.05, 1.02‒1.07, per 1% increase], and of tobacco smoking [0.97, 0.95‒0.99, per 1% increase] explained 71.5% of UC incidence variation across countries in the adjusted analysis. The model for CD included latitude [1.04, 1.02‒1.06], expenditure for health (1.03, 1.01‒1.05, per 100 purchasing power parity [PPP]/year per capita increase), and physical inactivity prevalence [1.03, 1.00‒1.06, per 1% increase], explaining 58.3% of incidence variation across countries. Besides expenditure for health, these associations were consistent in low/middle- and high-income countries. CONCLUSIONS: Our analysis highlights factors able to explain a substantial portion of incidence variation across countries. Further high-quality research is warranted to develop global strategies for IBD prevention.

The Case for Public Financing of Environmental Common Goods for Health.

Safeguarding the continued existence of humanity requires building societies that cause minimal disruptions of the essential planetary systems that support life. While major successes have been achieved in improving health in recent decades, threats from the environment may undermine these gains, particularly among vulnerable populations and communities. In this article, we review the rationale for governments to invest in environmental Common Goods for Health (CGH) and identify functions that qualify as such, including interventions to improve air quality, develop sustainable food systems, preserve biodiversity, reduce greenhouse gas emissions, and encourage carbon sinks. Exploratory empirical analyses reveal that public spending on environmental goods does not crowd out public spending on health. Additionally, we find that improved governance is associated with better performance in environmental health outcomes, while the degrees of people's participation in the political system together with voice and accountability are positively associated with performance in ambient air quality and biodiversity/habitat. We provide a list of functions that should be prioritized by governments across different sectors, and present preliminary costing of environmental CGH. As shown by the costing estimates presented here, these actions need not be especially expensive. Indeed, they are potentially cost-saving. The paper concludes with case examples of national governments that have successfully prioritized and financed environmental CGH. Because societal preferences may vary across time, government leaders seeking to protect the health of future generations must look beyond electoral cycles to enact policies that protect the environment and finance environmental CGH.

Effectiveness of the e-NurSus Children Intervention in the Training of Nursing Students.

The paediatric population is the most vulnerable to exposure to environmental risk factors. Institutions of higher education have to equip nursing students with the attitudes, knowledge, and skills to respond to this using blended learning. The aim of this study was to evaluate the effect of e-NurSus Children intervention on student nurses' attitudes, knowledge, and skills. A quasi-experimental study of time series was designed using pre and post educational intervention evaluation in 2018. The participants were nursing students (N = 267) from Spain (n = 110) and the United Kingdom (n = 157). Three instruments were used: the Sustainability Attitudes in Nursing Survey, the Children's Environmental Health Knowledge Questionnaire, and the Children's Environmental Health Skills Questionnaire. The attitudes (15.81%), knowledge (39.02%), and skills (29.98%) of nursing students improved following the e-NurSus Children intervention. It is necessary to include topics on children's environmental health in nurse education as students are aware of this issue but do not have the knowledge or skills required to manage problems or illness caused by the environment. The e-NurSus Children intervention is an effective tool to address this educational gap.