Keywords

Introduction

Creating a healing environment that nurtures the curing process requires paying attention to all that patients take into their bodies. In healthcare facilities, the administration of pharmaceuticals is a very strict action; primary interest is in what the patient eats, drinks and breathes: it ensures that the food is as healthy and balanced as possible, that the water is pure and it is drunk enough and that the outdoor air introduced in interiors is adequately filtered (D’Alessandro et al. 2016; Oppio et al. 2016). They are all correct and responsible actions, although, very often, the indoor air quality’s monitoring is neglected (Settimo 2012).

The study, to date still the most complete, led by IEMB (Indoor Environment Management Branch, Internal Environment Management Section), a section of EPA (Environmental Protection Agency, Agency for Environmental Protection Environmental), in 1998 had the aim to analyse and determine the relationship between indoor and outdoor environments between the concentrations and exposures to different air pollutants, including gases and volatile organic compounds (VOCs). The data analysis supported the hypothesis that the indoor exposure to the most of the examined pollutants greatly exceeds the outdoor one, approximately from 10 to 50 times more; the indoor concentrations generally are from 1 to 5 times greater than outdoor ones.

Although the deterioration of the indoor air quality cannot be attributed to a single cause, the main possible processes and factors that influence indoor air quality are as follows:

  • lower attention of designers in the localization and orientation of the buildings, as well as in the choice of appropriate technical solutions and the application of base rules (Capolongo et al. 2013);

  • measures for the reduction of the building energy consumption, such as better sealing and, simultaneously, a decrease of the ventilation;

  • the use of innovative materials that are not enough tested and therefore strongly unhealthy;

  • realization of lightweight constructions, appreciated for the low cost, for the operating speed and for the gain of usable area, but that inevitably require air-conditioning systems in order to ensure an adequate microclimatic comfort (Baglioni and Capolongo 2002; Morena 2015; Oberti 2014).

It is clear that the causes of indoor pollution are many and they are closely interrelated, and at the same time, it is possible to identify numerous types of pollutants’ sources. They can include building materials, finishing products, furniture, etc., and they are particularly important for their large contribution. Some contaminants are derived from human activities and other types of pollutants, such as bacteria, moulds and bodily excretions, and derived from human, pets and plants present in living spaces. Other substances are emitted from building maintenance and cleaning products (Signorelli and Riccò 2012).

As stated by several authors, one of the main factors is also the configuration of the room, its size, their solar orientation, the size of the openings, etc.: within the same building, it is possible to have different air quality in relation to the various factors related to the building itself and its exposure (Settimo 2012; Pisello et al. 2014).

Today, in many hospitals, especially in inpatient wards, one of the parameters that greatly influence the daily life of users is lighting. Conventionally, the technology adopted for the windows of the rooms does not involve any innovative solutions: internal or external blinds shade, and very little customization is allowed to patient (Buffoli et al. 2007). In most of the new hospitals, as already happened in several hotels, windows cannot be opened by the patients, since it would introduce too many variables in the costs of heating and cooling of the healthcare facility (Capolongo et al. 2014); in fact, air circulation and heating are controlled by the HVAC system for managing costs best and for controlling the quality of air.

In summary, the indoor pollutants can be attributed to building materials, finishing products and furniture, HVAC (heating, ventilation and air-conditioning system), cleaning and maintenance products, the presence of people and their activities and, in healthcare facilities, medical equipment too.

A Focus on the Emissions from Building Materials and Their Effects on Health

The most important pollutants emitted from building products that arouse great concerns are volatile organic compounds such as formaldehyde, acetaldehyde, naphthalene, toluene, xylene, isocyanates and the semi-volatile organic compounds (SVOCs), such as phthalates and halogenated flame retardants (Bottero et al. 2015; Huisman et al. 2012).

Volatile organic compounds (VOCs) are carbon compounds that can become a gas at the regular room temperatures and after it will tend to evaporate from a building product into the air over time where humans can breathe it in. VOC-type chemicals are used as feedstocks for some plastics and utilized in binders and other resins for products such as composite wood or insulation; paints, coatings and adhesives; and the treatments to guarantee water resistance or to enhance stain repellence.

Building material finishes and furniture containing VOCs include resilient flooring, carpet, wall covering, fabrics, furniture, ceiling tiles, composite wood products, insulation, paints and coatings, adhesives, stains, sealants and varnishes.

In particular, formaldehyde is used as a binder in composite wood and batt insulation and in the fabric manufacturing process to protect fabric against shrinking, for improved crinkle resistance, dimensional stability and colour fastness. It is also utilized as a component of some finish treatments to improve stain resistance.

VOCs are often emitted at high levels when a product is first installed and diminish gradually to lower levels over time related to cure time or drying time, of components that are initially wet and finally dry (Tucker 2000).

Flooring, fabric, furniture and furnishings, namely solid materials, emit VOC emissions more slowly at first and maintain a low level of emissions over a longer period of time. Many VOCs have direct health effects as well. Some of these have been associated with short-term acute sick building syndrome symptoms, as well as other longer-term chronic health effects, such as harm to the liver, kidney and nervous systems, and augmented cancer risk (in fact, IARC—International Agency for Research on Cancer—considers formaldehyde as group 2A, instead benzene and acetaldehyde, as group 2B) (IARC 1987).

One of the VOCs of greatest concern is formaldehyde, classified as a Group 1-known human carcinogen by the International Agency for Research on Cancer (IARC 2004). The US EPA’s Integrated Risk Information System (IRIS) estimates a cancer risk in humans of one in 10,000 at relatively low concentration levels (Beck et al. 2016; EPA 2015). Exposure to formaldehyde is also associated with decreased lung function and respiratory, eye, nose and throat irritation.

On the contrary, semi-volatile organic compounds (SVOCs) are compounds with higher vapour pressures than VOCs and they are released as gas much more slowly from materials. Moreover, they are likely to be transferred to humans by contact or by attaching to dust and being ingested.

Semi-volatile organic compounds are used in building materials to afford flexibility, in particular phthalates, water resistance or stain repellence, in particular, perfluorochemicals, as well as to inhibit ignition or flame spread, especially the halogenated flame retardants. Phthalates are found in soft polyvinyl chloride (PVC) building products, including vinyl flooring, upholstery, wall coverings, hospital and shower curtains. But they are also used in non-building materials, such as medical devices including tubing, blood bags and catheters.

Perfluorochemicals can be found in carpets, upholstery, textiles and furniture; in other situations in which stain resistance or water repellence are required, halogenated flame retardants are found in fabric and furniture, electronic equipment and foam pillows.

The concerns in indoor contamination by SVOCs are increasing because they can alter the hormones’ activity in humans and wildlife, well known as endocrine disrupting chemicals (EDCs). They are suspected to contribute to the neurological and behavioural development, reproductive abnormalities, metabolic disorders and cancer (Weschler and Nazaroff 2008).

As regards, instead, physical contaminants’ issues and fibrous insulations, under certain stress conditions, could be responsible for releasing mineral fibres into the air, so much more dangerous to health because their diameter is shorter and more easily breathable.

Heavy metals are other physical pollutant cause of concerns. They belong to the group of metallic elements extracted from mined ores that can be highly toxic in their elemental form or in compounds. Some of the ones that have raised most worries about human toxicity comprise arsenic, antimony, cadmium, chromium, copper, cobalt, lead, mercury and zinc. Heavy metals are used as stabilizers in vinyl plastic materials, that can be found in resilient flooring, ceiling titles coatings, window treatments, wall covering, carpet backing. In several building systems, and then also in healthcare facilities, heavy metals can be found throughout:

  • it is possible to found lead in copper and other roof products, solder and batteries and in some PVC products such as wire insulation jacketing and exterior cladding;

  • mercury can be in thermostats, switches and fluorescent lamps;

  • chromium VI can be traced in chrome or stainless steel components of furniture;

  • cadmium, cobalt, antimony trioxide and other metals may be incorporated into paint, dyes and pigments; fabric; and some PVC products such as resilient flooring.

Since heavy metals bioaccumulate and often are integrated in water system, human exposure becomes a criticism. Lead and mercury are potent neurotoxicants, particularly damaging the brains of foetuses and growing children (Martuzzi and Tickner 2004; Schettler et al. 2000). Cadmium is a carcinogen that can damage the kidney and lungs (Schettler et al. 2000); instead, chromium VI or hexavalent chromium is listed by the International Agency for Research on Cancer, as a carcinogen (IARC 2004).

The health effects influenced by exposure to indoor pollutants affect patients, staff and visitors. However, these effects indent not only building occupants, but also the broader community, because some building products used outside can release contaminants, such as fibres and particulates, contributing to smog formation. The effects do not finish with the local community: design decisions play out across the whole life cycle of the materials used into healthcare facilities, beginning with the extraction of the raw materials and their manufacture into building products and medical products till end of life. The life cycle analysis of the materials could often a negative picture of the same specific material and the polymeric materials, widely utilized both finishes and medical equipment due to their high performance, constitute a representative example.

Drilling for the oil and gas from which plastics are made emits cadmium, mercury and a large quantity of other toxic chemicals such as xylene, arsenic, chlorophenols and polycyclic aromatic hydrocarbons into the environment. The harmful releases go on at petroleum refineries, which emit naphthalene, lead and other toxic chemicals. The track of toxic chemical emissions goes on at each subsequent step along the path to manufacture a final plastic product. The production of PVC alone contributes releases of dioxins, ethylene dichloride and vinyl chloride monomer. End-of-life disposal proceeds the matter with the release of yet more toxic chemicals (Alfonsi et al. 2014).

The Choice of Green Materials

Improving indoor air quality and avoiding materials responsible for some of the worst toxic chemicals released into the environment should be the top priorities during the design decision-making, evaluating environmental performances of building materials (Buffoli et al. 2015; Oberti 2013a). It is fundamental to define what are environmentally preferable for green materials. Although there is not yet a definitive set of materials and product standards that define it, the scientific community converges on some basic criteria, so that the products or systems should have or be:

  • recyclable. Products are manufactured all or in part with recycled materials and can also be recycled after use. Using recycled products or products with recycled content is environment-friendly and supports the economy in several ways. A significant effect can be the decreasing need for manufacturing with virgin and non-renewable resources, which saves precious resources and also saves manufacturers’ investment. Materials that would have ended in landfills after its useful life instead can be reprocessed for use in other products. For example, newspapers can be reprocessed into cellulose insulation; plastic milk cartons can be shredded, melted and reprocessed into toilet partitions; and rubber from automobile tyres can be reprocessed into roofing and flooring materials;

  • renewable resources. Products are made with renewable resources rather than non-renewable. Depletion of the Earth’s resources is occurring at an alarming rate. By utilizing renewable energies, such as wind, solar, tidal, as well as renewable products, such as wood, grasses or soil, it is possible to reduce the impact on biodiversity and ecosystems (Brambilla Pisoni et al. 2009);

  • minimum waste. Products produce as little waste as possible in their manufacture, use and disposal. Buildings are big generators of waste: landfills are overflowing, especially with construction waste, which accounts for 40% of the usage at landfills. By utilizing methods of reuse and recycling of scrap and trimmings, employing strategies that minimize waste through the life cycle of a product, manufacturers can radically reduce the amount of products that are put into the waste stream (Bottero et al. 2015);

  • locally or regionally produced. Products manufacture closer to their use (within 350 km), produce less pollution in transportation and also support regional economies (Bottero et al. 2015);

  • low embodied energy. Vast amounts of energy are used in the production of building materials. The embodied energy of a product, sometimes, involves a complex series of processes that contribute heavily to the indoor pollution, the depletion of natural resources and the degradation of the earth. This embodied energy includes the energy necessary for extracting minerals and raw materials, the fuel necessary for transporting materials to the manufacturing site and the energy used at the plant to make the final products. Moreover, it includes the energy during the use and, later, disposal of the product (Brambilla Pisoni et al. 2009; Paleari et al. 2012);

  • low environmental and human impact. They are products that do not harm the environment, but cause air or water pollution or damage to the Earth, its inhabitants and its ecosystems in their manufacture, use or disposal. They are non-toxic and contribute to good indoor air quality, because they are produced in accordance with the twelve principles of Green Chemistry (Anastas and Warner 1998). Pollution caused in excavation, manufacture, use or disposal of a product can have untold consequences on ecosystem. Poor indoor air quality, caused by products emitting harmful substances, increases the risks to people’s health;

  • durable. They are products that are long-lasting and need little maintenance. Product replacement puts a strain on the earth, its resources and its inhabitants. In making products more durable and easy to maintain, manufacturers permit to eliminate costly, damaging and time-consuming processes of replacement (Buffoli et al. 2012; Capolongo et al. 2016).

It is impossible thinking that building industry changes suddenly, but some signals indicate an improvement: there are alternatives already on the market that illustrate the potential for greater sustainability and healthier products (Faggioli and Capasso 2015). In any case, considering all the possible constraints, for reaching sustainability in health care, the designers should focus the attention on the main components, which, if correctly designed, can drastically increase the overall (economic, social and environmental) performance of the facility. Currently, as Guenther and Vittori reported, there are many case studies that adoperate sustainable materials with different strategies (Guenther and Vittori 2014).

One of these alternatives is non-toxic plastic for its chemistry and renewability. Instead to be made from limited virgin material, like fossil fuels, they are originated by sustainable biobased resource; it is recyclable closed loop and, finally, biodegradable into healthy nutrients for food crops.

Plastics made from plants, called biobased plastics, are the new generation of plastic materials; such as the plastic, polylactic acid (PLA) is manufactured from corn rather than fossil fuels. Biobased plastics, such as PLA, have been in use for some time for select medical products and now they are starting to be utilized in fabrics and internal finishing materials such as wall protection systems and carpet. Linoleum flooring, wood cabinetry, cotton insulation and other biobased materials can be placed on the spectrum similarly to biobased plastics. Biobased materials are favoured over fossil fuel-based products for a wide variety of reasons: from their potentially inexhaustible renewable nature to the reduced global warming impact and avoidance of the environmental and human health impacts of fossil fuel exploration, extraction and refining (Oberti 2013b).

A further step in the research of sustainable strategies can be the use of natural fibres in insulation. Commonly, vegetable and animal ones are quite widespread, although these kinds of solutions are diffused in civil architecture, but not in hospital planning. Even though this criticism deficiency can be related to the suspicion on some hygiene related issues, currently there are several international companies that are developing healthy natural materials, already studied and certified.

The healthcare institutions have a very important leadership role in the decision-making of construction materials (Capolongo et al. 2014). Building materials’ selection is an important phase, especially for in-design hospitals or renovating activities, for reaching social and environmental sustainability, as several authors assert (Edwards 2010; Buffoli et al. 2015). It is influenced both to maximize environmental sustainability and to respect safety and comfort levels for users.

With important market power and the Hippocratic oath of “first do no harm”, health cares and other health systems are leading attempts from within the sector to source healthier building materials, to avoid products enclosing dangerous chemicals connected to cancer, respiratory problems and other hazardous health effects and to commit innovative strategies to move the market to research, develop and safer produce products.

Prevention is a fundamental principle of health care and public health. In the face of dubiety, precautionary action is appropriate to prevent injury. This public health approach makes sense both in the clinical setting and in responses to environmental and public health hazards. Similarly, a precautionary and preventive approach is an appropriate basis for decisions concerning material selection, design features, mechanical systems, infrastructure and operations and maintenance practices (Capolongo et al. 2016).