Indoor air quality, largely neglected and in urgent need of a refresh

While outdoor air quality is managed under the Resource Management Act 1991, which sets National Environmental Standards for outdoor air, no equivalent legislation exists for indoor air quality. The World Health Organization (WHO) recognises that healthy indoor air is a basic human right, stating that the quality of the air people breathe in buildings is an important determinant of health and wellbeing.3 According to the Environmental Protection Agency (EPA) in the United States (US), indoor air pollutant levels are typically two-to-five times higher than outdoor levels, and in some cases exceed outdoor levels of the same pollutants by a 100 times.4 Globally around 2.6 billion people still use solid fuels and kerosene for cooking, and the United Nations notes that indoor and ambient air pollution are the greatest environmental health risk.3 Time spent indoors combined with higher indoor concentrations of pollutants make the health risks associated with poor air quality usually greater indoors than outdoors. While initial public health efforts focused on measures to reduce fomite transmission, such as hand-washing, it is now well-recognised that airborne exposure is the predominant transmission route of SARS-CoV-2 (the virus that causes COVID-19).6 International consensus on airborne transmission was achieved in part through cutting-edge research conducted by New Zealand experts, but New Zealand health authorities have been slow to apply this key insight beyond border settings.7 It is imperative that national bodies responsible for the control of the pandemic incorporate the importance of airborne transmission to inform an evidence-based strategy and implement a range of highly effective measures that can prevent airborne transmission of the SARS-CoV-2 virus and other respiratory pathogens, including influenza.8-9'1011 The most effective approach to lowering concentrations of indoor air pollutants, including any pathogens that may be in the air, is usually to increase ventilation,12 exchanging polluted indoor air for cleaner outdoor air. Pollutant standards for heating and cooking appliances, particularly for appliances that use unflued gas should also be considered.20 An investment in clean indoor air could bring benefits other than reducing COVID-19 transmission, including reduced sick leave and school absenteeism caused by other respiratory infections, particularly influenza and other allergies.21 Less absenteeism-with associated adverse effect on productivity-could save companies significant costs.22 Furthermore, there is growing evidence that improved ventilation can improve cognitive functioning of workers and students,23 which can improve both wellbeing, sleep and productivity.24 Ventilation can also reduce indoor moisture particularly in homes, which wifi reduce exposure to respiratory allergens and irritants such as dust mites and mould, resulting in reduced incidence of asthma, rhinitis and allergy symptoms.

Investigation of healthcare-associated SARS-CoV-2 infection: Learning outcomes from an investigative process in the initial phase of the pandemic.

Background: Healthcare-associated (HCA) SARS-CoV-2 infection is a significant contributor to the spread of the 2020 pandemic. Timely review of HCA cases is essential to identify learning to inform infection prevention and control (IPC) policies and organisational response. Aim: To identify key areas for improvement through rapid investigation of HCA SARS-CoV-2 cases and to implement change. Methods: Cases were identified based on date of first positive SARS-CoV-2 PCR sample in relation to date of hospital admission. Cases were reviewed using a structured gap analysis tool to identify key learning points. These were discussed in weekly multidisciplinary meetings to gain consensus on learning outcomes, level of harm incurred by the patient and required actions. Learning was then promptly fed back to individual teams and the organisation. Findings: Of the 489 SARS-CoV-2 cases admitted between 10th March and 23rd June 2020, 114 suspected HCA cases (23.3%) were reviewed; 58/489 (11.8%) were ultimately deemed to be HCA. Five themes were identified: individual patient vulnerability, communication, IPC implementation, policy issues and organisational response. Adaptations to policies based on these reviews were completed within the course of the initial phase of the pandemic. Conclusion: This approach enabled timely learning and implementation of control measures and policy development.

Impact of the COVID-19 pandemic on the detection and management of colorectal cancer in England: a population-based study.

BACKGROUND: There are concerns that the COVID-19 pandemic has had a negative effect on cancer care but there is little direct evidence to quantify any effect. This study aims to investigate the impact of the COVID-19 pandemic on the detection and management of colorectal cancer in England. METHODS: Data were extracted from four population-based datasets spanning NHS England (the National Cancer Cancer Waiting Time Monitoring, Monthly Diagnostic, Secondary Uses Service Admitted Patient Care and the National Radiotherapy datasets) for all referrals, colonoscopies, surgical procedures, and courses of rectal radiotherapy from Jan 1, 2019, to Oct 31, 2020, related to colorectal cancer in England. Differences in patterns of care were investigated between 2019 and 2020. Percentage reductions in monthly numbers and proportions were calculated. FINDINGS: As compared to the monthly average in 2019, in April, 2020, there was a 63% (95% CI 53-71) reduction (from 36 274 to 13 440) in the monthly number of 2-week referrals for suspected cancer and a 92% (95% CI 89-95) reduction in the number of colonoscopies (from 46 441 to 3484). Numbers had just recovered by October, 2020. This resulted in a 22% (95% CI 8-34) relative reduction in the number of cases referred for treatment (from a monthly average of 2781 in 2019 to 2158 referrals in April, 2020). By October, 2020, the monthly rate had returned to 2019 levels but did not exceed it, suggesting that, from April to October, 2020, over 3500 fewer people had been diagnosed and treated for colorectal cancer in England than would have been expected. There was also a 31% (95% CI 19-42) relative reduction in the numbers receiving surgery in April, 2020, and a lower proportion of laparoscopic and a greater proportion of stoma-forming procedures, relative to the monthly average in 2019. By October, 2020, laparoscopic surgery and stoma rates were similar to 2019 levels. For rectal cancer, there was a 44% (95% CI 17-76) relative increase in the use of neoadjuvant radiotherapy in April, 2020, relative to the monthly average in 2019, due to greater use of short-course regimens. Although in June, 2020, there was a drop in the use of short-course regimens, rates remained above 2019 levels until October, 2020. INTERPRETATION: The COVID-19 pandemic has led to a sustained reduction in the number of people referred, diagnosed, and treated for colorectal cancer. By October, 2020, achievement of care pathway targets had returned to 2019 levels, albeit with smaller volumes of patients and with modifications to usual practice. As pressure grows in the NHS due to the second wave of COVID-19, urgent action is needed to address the growing burden of undetected and untreated colorectal cancer in England. FUNDING: Cancer Research UK, the Medical Research Council, Public Health England, Health Data Research UK, NHS Digital, and the National Institute for Health Research Oxford Biomedical Research Centre.

Maintaining Standards in Colorectal Cancer Surgery During the Global Pandemic: A Cohort Study.

AIM: Cancer surgery in the COVID-19 pandemic presents many new challenges. For each patient, the risk of contracting COVID-19 during the perioperative period, with the potential for life-threatening sequelae (1), has to be weighed against the risk of delaying treatment. We assessed the response and short-term outcomes from elective colorectal cancer surgery during the pandemic at our institution. METHOD: We report a prospective cohort study of all elective colorectal surgery cases performed at our Trust during the 11 weeks following the national UK lockdown on 23rd March 2020, compared with the same time period in 2019. RESULTS: Eighty-five colorectal operations were performed during the 2020 (COVID) time period, and 179 performed in the 2019 (non-COVID) time period. A significantly higher proportion of cases during the COVID period were cancer-related (66% vs 26%, p < 0.00001). There was no difference in length of hospital stay, complications or readmissions. There were no mortalities in either cohort. Among the cancer patients, there were no differences in TMN staging, R1 resection rate or lymph node yields. No elective patient tested positive for COVID-19 during the perioperative period. CONCLUSION: At the height of the COVID pandemic, we maintained delivery the of high-quality elective colorectal cancer surgery, with no worsening of short-term outcomes and no compromise in the quality of cancer resections. Ongoing monitoring of this cohort is essential. The risks associated with COVID-19 will continue for some time, necessitating adaptive responses to maintain high-quality cancer services.