There have been several concerns about the environmental persistence of SARS-CoV-2 virus. These concerns led to the formulation of sanitation measures that try to lower the risk of indirect transmission of SARS-CoV-2 in non-medical facilities.  This manuscript will elucidate the topic of environmental persistence of SARS-CoV-2. This will benefit the occupational health professionals two-fold. It describes the proper techniques for an effective sanitation of the workplace. It also explains how to protect workers who are responsible for carrying out these interventions. Sanitation is an important measure for a safe workplace. Sanitation is legally established and referenced by all the decrees so far enacted by the Italian government. It is defined as a set of actions and procedures that aim to lower the risk of indirect transmission of SARS-CoV-2 virus

A. Varone

E. Pacella

E. Trovato Battagliola

M. Malvasi

M. Sordilli

P. Bet

P. Tanzilli

S. Desio

English

Archivio della ricerca- Università di Roma La Sapienza

S&S                              Senses Sci 2020: 7 (3)1063-1067                                                                          doi: 10.14616/sands- 2020-3-10631067  www.sensesandsciences.com  Article Sanitation: a set of interventions mandated by the Italian government to limit the spread of SARS-CoV-2 in non-medical facilities  P. Tanzilli 1, A. Varone 1, P.Bet 2, S. DeSio3, M. Sordilli 1, E. Trovato Battagliola4, M. Malvasi4, E. Pacella4*   1 Department of Prevention UOC PRESAL, ASL Frosinone (Frosinone, Italy) 2 Technician for prevention of environment and in the workplace 3 Research Unit of Occupational Medicine, Sapienza University of Rome, Italy. 4 Department of Sense Organs, Faculty of Medicine and Dentistry, Sapienza University of Rome, Rome, Italy.  *Correspondence: Pacella Elena. Email: elena.pacella@uniroma1.it   Abstract. There have been several concerns about the environmental persistence of SARS-CoV-2 virus. These concerns led to the formulation of sanitation measures that try to lower the risk of indirect transmission of SARS-CoV-2 in non-medical facilities.  This manuscript will elucidate the topic of environmental persistence of SARS-CoV-2. This will benefit the occupational health professionals two-fold. It describes the proper techniques for an effective sanitation of the workplace. It also explains how to protect workers who are responsible for carrying out these interventions. Sanitation is an important measure for a safe workplace. Sanitation is legally established and referenced by all the decrees so far enacted by the Italian government. It is defined as a set of actions and procedures that aim to lower the risk of indirect transmission of SARS-CoV-2 virus.     Keywords: SARS-CoV-2, sanitation, occupational medicine, ozone, ultraviolet radiation                                                              Tanzilli, Varone, Bet Senses Sci 2020; 3: 1063-1067     Introduction     Concerns regarding SARS-CoV-2-related pneumonia were first publicly announced by the Italian Ministry of Health on Jan 22nd, 20201. This announcement included general public health measures that aimed to contain the spread of the virus. Mention was made about a cluster of pneumonia of unknown etiology in Wuhan, in the Chinese province of Hubei. Most of these cases could be traced back to a common place: a fish and livestock market.  On Jan 9th, 2020, the Chinese Center for Disease Control and Prevention had announced the spread of a new strain of coronavirus that was likely responsible for these cases of pneumonia and acute respiratory distress syndrome. The Chinese government ordered the closure and sanitation of the fish market.     It was later confirmed that the new coronavirus was able to survive in the environment for several hours. With these raising concerns, the WHO started to advocate for environmental sanitation as an important step to stop the spread of the virus2. The Italian government also started to promote and subsidize sanitation interventions. Estimates on the environmental persistence of SARS-CoV-2 virus were made by drawing comparisons with similar strains of coronavirus. If mixed with biological fluids, the coronavirus can survive up to 96 hours in the environment and up to 72 hours on porous surfaces.3 Survival rate is also influenced by the presence of dirt on the surface, environmental humidity, and temperature. The virus is stable at 4 degrees Celsius, but sensitive to temperature elevations. At 70 degrees Celsius, for example, the virus can remain viable for 5 minutes only 3.    On Feb 22nd, 2020, the Italian Ministry of Health detailed the modalities of sanitation for spaces potentially contaminated by SARS-CoV-24. Measures are explained in the following decree: “Protocolli condivisi di regolamentazione delle misure per il contrasto e il contenimento della diffusione del virus Covid-19 negli ambienti di lavoro” 3,7,8,9,10.    In the Italian law, sanitation is defined by the norms of the art. 1. of DM n. 274 of 7th July 1997, of the Ministry of Commerce and Industry. These norms consider sanitation as “activities that concern the complex procedures and operations that are needed in order to restore a healthy and safe environment, through cleaning and disinfection procedures; also through the control and improvement of the microclimatic conditions such as temperature, humidity, ventilations, also for illuminations and noise”.     Therefore, the process of sanitation is not limited to disinfection of surfaces. It consists of a set of actions and procedures that lower the overall risk of viral transmission11. For this reason, sanitation procedures cannot be limited to cleaning interventions. The sanitation process must actively involve all employees. Generic interventions are not sufficient. Businesses should evaluate the risk derived from each activity. For example, they should identify areas and instruments more likely to be contaminated by the virus, assess the type of material to disinfect, the frequency of potential contamination of surfaces, and numerous other factors.     Elements that might prevent from an effective environmental sanitation must be addressed. For example, surfaces should be free of objects and rooms should be efficiently ventilated. Both chemical      Sanitation interventions to limit the spread of SARS-CoV-2 in non-medical facilities      and physical agents can be used for disinfection. Focused interventions to areas that are more likely to become contaminated can prevent the need for more expensive and intensive interventions. Tools that are frequently used should be disinfected after every use. For this purpose, users should be instructed on how to properly disinfect these. Cleaning agents, gloves, and instructions on how to dispose of the contaminated material should be provided12. It is important to note that disinfection procedures constitute an infection risk per se. For this reason, workers should be properly instructed. They should be instructed on the products to use, the types of personal protective devices to wear, and procedures to follow even in emergency situations13,14. These different phases might require the supervision of the occupational physician. The cleaning products must be approved for this use. The most effective chemical agents include ethyl alcohol 62-71%; hydrogen peroxide 0.5%; sodium hypochlorite 0.1% applied for at least one minute.    It is important to note that these chemical agents can constitute a health hazard. They are corrosive and irritant. The biological risk can be both dose-dependent (acute or chronic intoxication) or dose-independent (hypersensitivity). The assessment and management of this type of risk is regulated by the D.L.gs 81/08 (Title IX “Dangerous Substances”). Ozone can be used to sterilize both medical and non-medical equipment. Other methods include UV rays of short wavelength (220 nm) or vaporization/aerosolization of hydrogen peroxide. Ozone or UV lamps should be considered for surfaces that cannot be treated with chemical agents or are difficult to reach.    Ozone is a classified as a dangerous substance10,15. It irritates the eyes and the upper respiratory tract. Long-term exposure is dangerous for the respiratory apparatus as it leads to irreversible parenchymal remodeling and compromises the respiratory function. It is listed in Group 1 in the IARC (2016) classification. It is an environmental pollutant and is carcinogenic to humans. Proper technical and organizational measures should be implemented to reduce the exposure risk of ozone to workers. These measures include proper education, medical surveillance, and use of personal protective equipment. The ECHA website describes how to lower this risk13.    UV rays can also be used for disinfection16. UV rays induce mutations in microbial DNA or RNA that impede replications. They are used to disinfect water, air, and foods. Radiations are dangerous to human eyes and skin. They are classified as Group 1 carcinogens on the IARC classification. The Italian law D.lgs n. 81/2008 sets exposure limits to reduce the dangerous sequelae of these radiations to eyes and skin. The efficacy of UV-C emitting lamps can be hindered by dust. Their effectiveness is also time-dependent. These types of lamps can complement conventional cleaning, but should be deployed at night, when work personnel is not present. Recent studies have shown that short wavelengths (between 200 and 222 nm) are effective to inactivate pathogens without being cytotoxic for human cells9,17.                                                           Tanzilli, Varone, Bet Senses Sci 2020; 3: 1063-1067     Conclusions     Sanitation is of utmost important to lower the risk of indirect transmission of SARS-CoV-2. The need for sanitation is reiterated in each decree enacted since the beginning of the pandemic. A careful assessment and planning are important to ensure that this process is executed effectively. The risk derived from the sanitation process should be assessed and mitigated, as mandated by the D.L.gs 81/08 18. Different techniques and chemical agents with proven virucidal activity can be deployed15,16. Elements that prevent from an effective sanitation should be identified and removed. In door ventilation should be improved. The whole process should be documented. Notes should be made on the types of interventions adopted, the different phases, and the protective measures for those who carry out the sanitation process. All activities should be recorded as they constitute a fundamental element to lower the spread of SARS-CoV-2 in the workplace19.   References  1. Circular 0001997-22/01/2020-DGPRE-DGPRE-P Ministry of Health Italian General Directorate of Health Prevention Office 05 - Prevention 2. Transmission of SARS-CoV-2: implications for infection prevention precautions, Scientific Brief,www.who.int/publications-detail-redirect/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations. 3. ISS Working Group on Infection Prevention and Control COVID-19. Interim guidance for sanitizing indoor environments in the health and care setting to prevent transmission of SARS-CoV 2. Version of May 14, 2020. Rome: Istituto Superiore di Sanità; 2020. (ISS COVID-19 Report, No. 20/2020 Rev.).  4. Ministry of Health Circular No. 5443 dated February 22, 2020 with the subject "COVID 19. New guidance and clarifications." 0005443-22/02/2020-DGPRE-DGPRE-P 5. DPCM April 26, 2020 Gazzetta Ufficiale Serie Generale n.108 of 27-4-2020 https://www.lavoro.gov.it/notizie/Documents/Protocollo-24-aprile-2020-condiviso-misure-di-contrasto%20Covid-19 . 6. www.gazzettaufficiale.it/eli/id/2020/12/03/20A06767/sg Prime Ministerial Decree December 3, 2020 .  7. ISS Environment and Indoor Air Quality Working Group. Directions for the prevention and management of indoor environments in relation to the transmission of SARS-CoV-2 virus infection. Version of April 21, 2020. Rome: Istituto Superiore di Sanità; 2020. (ISS Report COVID-19, No. 5/ 2020 Rev.).  8. ISS Infection Prevention and Control COVID-19 Working Group. Interim guidance for sanitizing indoor environments in the health and care setting to prevent transmission of SARS-CoV 2. Version of May 14, 2020. Rome: Istituto Superiore di Sanità; 2020. (ISS COVID-19 Report, No. 20/2020 Rev.).       Sanitation interventions to limit the spread of SARS-CoV-2 in non-medical facilities      9. ISS Biocides COVID-19 Working Group. Interim recommendations on sanitizing non-health care facilities in the current COVID-19 emergency: surfaces, indoor environments, and clothing. May 15, 2020 version. Rome: Istituto Superiore di Sanità; 2020. (ISS COVID-19 Report No. 25/2020).  10. ISS-INAIL Working Group. Focus on: professional use of ozone also with reference to COVID-19. Version of July 23, 2020. Rome: Istituto Superiore di Sanità; 2020. (ISS COVID-19 Report No. 56/2020). 11. Loffredo L, Pacella F, Pacella E, Tiscione G, Oliva A, Violi F. Conjunctivitis and COVID-19: A meta-analysis. J Med Virol. 2020 Sep;92(9):1413-1414. doi: 10.1002/jmv.25938. Epub 2020 May 22. PMID: 32330304; PMCID: PMC7264785. 12. De Sio S, Goglia C, Cristaudo A, Pacella E, Romanelli F, Santilli V, Vitarelli A, Mandolesi D, Balladore F, Nieto H. Italy and Argentina compared: an epidemiological study of occupational diseases. Ann Ig. 2016 Jan-Feb;28(1):50-7. doi: 10.7416/ai.2016.2084. PMID: 26980509. 13. Schwarz L, Lwowski C, Schmack I, et al. [Ophthalmological care of SARS-CoV-2 positive patients in intensive care units]. Der Ophthalmologe : Zeitschrift der Deutschen. Ophthalmologischen Gesellschaft. 2020 Jul;117(7):602-608. DOI: 10.1007/s00347-020-01159-6. 2017 Aug 16. PMID: 28812184. 14. Pacella F, Collini S, Angelucci F, Agostinelli E, Guzzo AS, Cerza C, Pacella E. Infections in hospital departments. What is Hospital Responsibility? Clin Ter. 2017 Jul-Aug;168(4):e266-e270. doi: 10.7417/T.2017.2018. PMID: 28703843. 15. Cestonaro LV, Marcolan AM, Rossato-Grando LG, Anzolin AP, Goethel G, Vilani A, Garcia SC, Bertol CD. Ozone generated by air purifier in low concentrations: friend or foe? Environ Sci Pollut Res Int. 2017 Oct;24(28):22673-22678. doi: 10.1007/s11356-017-9887-3. Epub  16. Lai ACK, Nunayon SS, Tan TF, Li WS. A pilot study on the disinfection efficacy of localized UV on the flushing-generated spread of pathogens. J Hazard Mater. 2018 Sep 15;358:389-396. doi: 10.1016/j.jhazmat.2018.07.003. Epub 2018 Jul 3. PMID: 30005250; PMCID: PMC7116983. 17. Nipunie Rajapakse 1, Devika Dixit. Human and novel coronavirus infections in children: a review. Paediatr Int Child Health. 2020 Jun 25;1-20. doi:10.1080/20469047.2020.1781356. 18. Darnell ME, Subbarao K, Feinstone SM, Taylor DR. Inactivation of the coronavirus that induces severe acute respiratory syndrome, SARS-CoV. J Virol Methods. 2004 Oct;121(1):85-91. doi: 10.1016/j.jviromet.2004.06.006. PMID: 15350737; PMCID: PMC7112912. 19. Legislative Decree 9 April 2008, n. 81 - National Labor Inspectorate    

Sanitation: a set of interventions mandated by the Italian  government  to  limit  the  spread  of SARS-CoV-2 in non-medical facilities

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Sanitation: a set of interventions mandated by the Italian government to limit the spread of SARS-CoV-2 in non-medical facilities

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