Monitoring of the Environmental Contamination and Exposure Risk of COVID-19 in the Medical Staff of Coronavirus referral hospitals in Qom, Iran

Journal of Environmental Treatment Techniques

2021, Volume 9, Issue 2, Pages: 178-182

J. Environ. Treat. Tech.

ISSN: 2309-1185

Journal web link: http://www.jett.dormaj.com

https://doi.org/10.47277/JETT/9(1)182

Monitoring of the Environmental Contamination

and Exposure Risk of COVID-19 in the Medical

Staff of Coronavirus referral hospitals in Qom,

Iran

Saeed Shams , Rahim Aali , Mehdi. Safa , Yadollah. Ghafuri , Zahra. Atafar

Cellular and Molecular Research Center, Qom University of Medical Sciences, Qom, Iran

Research Center for Environmental Pollutants, Qom University of Medical Sciences, Qom, Iran

Social Development & Health Promotion Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran

Received: 14/08/2020

Accepted: 25/10/2020

Published: 20/03/2021

Abstract

COVID-19 is a new infection that first occurred in China and now is spreading worldwide. The disease is considered to be a serious

respiratory disease in humans. This study has been designed to assess surface contamination of SARS-CoV-2and exposure risk of the

disease in the medical staff of two coronavirus referral hospitals of Qom province, which were dedicated to the admission and treatment

of COVID -19 patients.. This study was carried in two steps including analysis of environmental samples and exposure risk assessment

of COVID-19. In this study 50 environmental samples were collected from different sites of the hospitals. After extracting RNA, RT-

PCR was done for the detection of SARS-CoV-2. The results showed that 18% of environmental sites, including elevator buttons (8%),

doorknobs (6%) and bed rails (4%) were positive. In the risk assessment process based on according to wear of personal protective

equipment, exposed to high touch surfaces, performing hand hygiene, any accident with biological fluid/respiratory secretions, the results

indicate that 60.4 %, 68.3%, 28.6% and 20.6% health care personal including medical doctors, nurses and assistant nurses have high

risk, respectively. In general, implement a plan for monitoring health personnel exposed to confirmed COVID-19 cases for respiratory

illness including environmental surveillance engineering controls and personal protective equipment recommended.

Keywords: COVID-19; Environment; Risk; Exposure; Hospitals

contamination of COVID-19 and exposure risk of the disease

in the medical staff of coronavirus admission hospitals in Qom

province.

Introduction

Coronavirus disease (COVID-19) is an infectious disease

affected by a new coronavirus. The disease causes flu-like

respiratory illness with different symptoms such as cough,

fever, shortness of breath, and breathing difficulties, etc. (1, 2).

In more severe cases, the disease can causes multiple organ

failures and even death. This virus is the same member of the

coronavirus family that caused the severe acute respiratory

syndrome coronavirus (SARS-CoV) reported in China in 2003

and the Middle East Respiratory Syndrome (MERS-CoV)

reported in Saudi Arabia in 2012. The initial cases of the

COVID-19 have been linked to a live seafood market in

Wuhan, China, December 2019 that was originated from an

animal source and adapted to other variants as it crossed the

species barrier to infect humans (3). Following the guidance of

WHO on infection prevention and control strategies, it is

important to ensure that environmental cleaning and

disinfection procedures are consistently and correctly followed.

Cleaning environmental surfaces with water and detergents and

applying commonly used hospital-level disinfectants (such as

sodium hypochlorite) are known as effective and sufficient

procedures. Medical devices, equipment, laundries, food

service utensils, and medical wastes should be managed in

accordance with safe routine procedures (4, 5). This study was

designed to assess the extent and persistence of surface

2 Material and Methods

2.1 Study setting

The study was planned in Qom, as the first city that

identified the disease in in the central part of Iran, with about

1.3 million residents, Two coronavirus referral hospitals of

Qom, Kamkar and Forghani hospitals, which dedicated to the

admission and treatment of COVID -19 patients, were included

in this study. Their location is showed in Figure 1.

2.2 Collection of environmental samples

Fifty environmental samples including Ambulance patient

carrier, Corridor and patient entrance, Admission and Waiting

room, Patient room…were collected using sterile swabs with

synthetic tips and plastic shafts. Each swab was placed into a

tube containing 2 ml of the viral transport medium (VTM) that

was labeled and and putted in a self-sealing bag. Then, the

outside of the sealed bag was disinfected by 5% hypochlorite

solution. In each sampling round a set of control samples also

were collected. The first set of control samples were handled in

the same way as the environmental samples from the

potentially contaminated area, including opening the package

Corresponding author: Yadollah. Ghafuri, Research Center for Environmental Pollutants, Qom University of Medical Sciences, Qom,

Iran. Tel: +98 25 32852740 E-mail: yadollahghafuri@yahoo.com

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Journal of Environmental Treatment Techniques

2021, Volume 9, Issue 2, Pages: 178-182

and removing the swab from the tube, but without sampling any

surfaces. The second set of control samples remains sealed, but

was shipped, stored and tested with the surface samples, to

exclude contamination later on. Next, the collected samples

were immediately transferred to a clinical virology laboratory.

For each sample collected a questionnaire including site,

sampling location, ambient temperature, humidity, the situation

of disinfection including disinfectant, and the last time

disinfected before sampling were completed. In Table 1,

sampling sites have been described based on location in

selected hospitals (6).

pM), 5.5 µl distilled water, and 5 µl of cDNA. The RT-PCR

program was included initial denaturation at 94 ˚C for 4 min (1

cycle), followed by 40 cycles of denaturation at 94 ˚C for 35s,

annealing at 55 ˚C for 35s, and extension at 72 ˚C for 35 s. Final

extension was carried out at 72 ˚C for 5 min (1 cycle). PCR

products were analyzed by electrophoresis on agarose gel

stained with DNA safe dye.

2.4 Exposure risk assessment of COVID-19

In order to assessment of risk, WHO guidance was used

(9,10) In each hospital,33 medical staff including doctor,

nurse, and assistant nurse ,who had the highest level of contact

with patients, were selected and then interviewed with

questions about exposure with COVID -19. A simplified risk

exposure category based on most common scenarios with a

focus on infection prevention and source control measures

including use-wear of personal protective equipment (PPE) by

health care personal and degree of close contact with the

COVID-19 patients were considered. According to this, the

criteria of exposure risk assessment of COVID-19 for health

workers were direct defined care and/or close contact (at a

distance of one meter) with confirmed COVID-19 patients, and

any aerosol-generating procedures performed on them (9, 11).

The risk categorization of health workers exposed to the

COVID-19 is described in Table 2.

.3 Detection of SARS-Cov-2

Viral RNA extraction was done by a commercial kit

(

SinaClon, Iran) according to the manufacturer's protocol.

cDNA was synthetized by a mix of template RNA (10 µl), RT

enzyme (1 µl), oligo (dT) (1 µl), and distilled water (4 µl) at

2 C (40 min) and 85 C (5 min) using using cDNA synthesis

kit (BioFact, South Korea).Briefly, For RT- Polymerase chain

reaction (Reverse Transcription-PCR) ,two sets of primers

(

designed

this

study),

Forward

(5´

GTTTCGGAAGAGACAGGTAC-3´) and Reversed (5´-

AGAATTCAGATTTTTAACACGAGAG-3´) were used to

amplify a fragment of 189 bp regarding the E gene. The total

volume of the reaction mixture was 25 µl contained 12.5 µl of

x Master Mix (Ampliqon, Denmark), 1 µl of each primer (10

Figure 1: Location of studied area

Table 1: Sampling sites based on location in hospitals selected

Sampling locations

Ambulance patient carrier

Sampling sites

Medical bag handle

Blood pressure cuff

Stretcher

Doorknob

Light switch

Sink

Doorknob

Key board

Clothes

Number of sample collected

Corridor and patient entrance

Admission and Waiting room

Staff room

Patient room

Doorknob,

Bed rails

Elevator button

Patient handling

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Journal of Environmental Treatment Techniques

2021, Volume 9, Issue 2, Pages: 178-182

Table 2: Risk categorization of health workers exposed to COVID-19

Risk

categorization

Defined criteria

Questions

The health worker did not

respond “Always, as

recommended” to

Questions:‘Always, as

recommended’ should be

considered wearing the PPE

when indicated more than

-During the period of a health care interaction with a COVID-19 patient, did

the health worker wear PPE including single gloves, medical mask, face

shield or goggles/protective glasses, and disposable gown?

-During the period of health care interaction with the COVID-19 case, were

high touch surfaces decontaminated frequently (at least three times daily)?

High risk

95% of the time;

During the period of a health care interaction with a COVID-19 infected

patient, did the health worker have any episode of accident with biological

fluid/respiratory secretions?

The health worker responded

Yes”

“

During the period of a health care interaction with a COVID-19 patient,

did the health worker wear personal protective equipment (PPE) including

single gloves, medical mask, face shield or goggles/protective glasses, and

disposable gown?

The health worker responded - Did the health worker remove and replace your PPE according to protocol

“

Most of the time,

Occasionally, Rarely”

Most of the time’ should be

(e.g. when medical mask became wet, disposed the wet PPE in the waste

bin, performed hand hygiene, etc)?

- During the period of health care interaction with the COVID-19 case, did

the health worker perform hand hygiene before and after touching the

COVID-19 patient?

‘

considered 50% or more but

not 100%; ‘occasionally’

should be considered 20% to NB: Irrespective of wearing glove

Low risk

under 50% and ‘Rarely’

should be considered less

than 20%.

- During the period of health care interaction with the COVID-19 case, did

the health worker perform hand hygiene after touching the COVID-19

patient’s surroundings

(

bed, door handle, etc)?

During aerosol generating procedures on the

COVID-19 patient, did health worker remove and replace your PPE

according to protocol.

During aerosol generating procedures on the

COVID-19 case, did you perform hand hygiene

before and after touching the COVID-19 patient, after touching the COVID-

19 patient’s surroundings (bed, door handle, etc)?

health care personal with COVID -19 according to risk of close

contact with patients are summarized in the Tables 4and 5,

respectively.

Results

Eighteen percent of evaluated samples by RT-PCR assay,

including 3 doorknob sites (6%), 4 elevator button sites (8%),

and 2 bed rail (4%) were positive for SARS-CoV-2. In figure

, gel electrophoresis is showed.

4 Discussion

The results of our study showed that 18% of samples

evaluated by RT-PCR assay were positive for SARS-CoV-2 ,

including 3 doorknob sites (6%), 4 elevator button sites (8%)

and 2 bed rails (4%). Other samples including clothes of staff,

keyboard, and stretchers of the ambulance, patient carriers,

patient room, and light switch were negative, resulting in

current decontamination measures were sufficient. It seems that

one of the reasons for contamination in some surfaces can be

related to the high load of visits and contact with these in

comparison with others. In this study, according to the

diagnostic method used, no information was obtained about the

viability and number of virus on the surfaces. In the study of

Kampf et al. on the persistence of coronaviruses on inanimate

surfaces and their inactivation with biocidal agents, their results

indicated that coronaviruses (HCoV) could persist on different

inanimate surfaces like metal, glass or plastic for up to 9 days,

but could efficiently inactivate by surface disinfection

procedures such as 71% ethanol, 0.5% hydrogen peroxide or

Figure 2: Agarose gel electrophoresis. Lane M, 100 bp molecular

weight marker; lane NC, negative control; lanes 1-3, positive samples

In Table 3, the features of positive sites in hospital selected

is presented. The effect of three types of disinfectants on

SARS-CoV-2and the risk assessment and potential exposure of

0.1% sodium hypochlorite within one minute (12).

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2021, Volume 9, Issue 2, Pages: 178-182

Table 3: Features of positive sites in health care settings

Positive

sampling

two hospitals

Number of The

last

time Disinfectant type

Concentration

(%)

Temperature

( ºC)

Humidity

(%)

in samples

disinfected before

sampling (h)

Doorknob

Elevator

Button

Sodium hypochlorite

0.2

Bed rails

Sodium hypochlorite

0.2

Table 4: Effectiveness of three types of disinfectants on SARS-CoV-2

Concentration Number of total Positive sample Exposure time

Disinfectant

Temperature

( ºC)

(

sample

after disinfection

(min)

Sodium hypochlorite

Hydrogen peroxide

Peracetic acid

0.2

0.5

0.25

Table 5: Risk assessment and potential exposure of health care personal

any accident with

biological

fluid/respiratory

secretions

Number

of case

Evaluated

in two

wear of PPE

exposed to high touch performing hand

surfaces

hygiene

Personal

Low-

risk

Low-

risk

(%)

Low-

risk

(%)

High-risk

(%)

High-risk

(%)

High-risk Low-risk

hospitals

(

(%)

(

Doctor

14.2

12.9

33.3

57.1

48.3

57.1

14.2

16.1

42.8

14.2

7.1

3.2

9.5

Nurse

Assistant nurse

9.6

6.4

14.2

So, it is consistent with the results of the present study.

Study of Jiang et al. about hospital environmental hygiene

monitoring by quantitative real-time PCR methods, showed

that viruses could be detected on the surfaces of the nurse

station in the isolation areas with suspected patients and also in

the air of the isolation ward with an intensive care patients (13,

protocols attention, environmental factors and hazards are

inevitable(17, 18).

Conclusion

Our report is one of the first to demonstrate the

contamination of the hospital surfaces with SARS-CoV-2. Our

findings also emphasize the concern of the exposure risk of the

personnel of hospitals with COVID-19. Therefore, a regular

program should be adopted to monitor the disinfection of

surfaces and the proper use of personal protective equipment in

high-risk health personnel, as well as environmental controls

and hospital equipment.

5).The results of the effectiveness of the three disinfectant

compounds including sodium 0.2%, hypochlorite 0.2%

hydrogen peroxide and 0.25% Peracetic acid is presented in

Table 3. Due to the negative results of all samples after

disinfection for three compounds of disinfectant, it has the

same effectiveness in the concentrations used which is similar

to the results of other available studies and reports (13, 14).

Risk assessment and potential exposure of health care personal

with COVID -19 according to wear of PPE, exposed to high

touch surfaces, performing hand hygiene, any accident with

biological fluid/respiratory secretions, the results indicated

Acknowledgments

We thank the staff of Kamkar and Forghani Hospitals of

Qom University of Medical Sciences.

0.4 %, 68.3%, 28.6%, and 20.6% health care personal

Ethical issue

including doctors , nurses and assistant nurses,respectively.

However, the results are different for assessing the risk of

exposure to the patient’s equipped personal protection (control

at source) and include 12.8% and 15.1% for high and medium

risk, respectively. Other studies have been documented

increased transmission risk associated with COVID -19 among

health care personnel. Heinzerling et al. evaluated health care

personnel who were tested for SARS-CoV-2 and participated

in interviews, according to PPE use and exposure

characteristics and assessed for transmission of COVID-19,

their findings indicated that 77% of personnel having high and

medium risk (10, 11). Risk exposure to COVID-19 in pregnant

healthcare workers reported by Belingheri et al. They showed

that pregnant worker should not be exposed to confirmed or

suspected COVID-19 patients, even if they wear appropriate

personal protective equipment (16). This result is compatible

with the present study. In order to respond and control the

transmission and expansion of COVID-19 according to WHO

Authors are aware of, and comply with, best practice in

publication ethics specifically with regard to authorship

(

avoidance of guest authorship), dual submission, manipulation

of figures, competing interests and compliance with policies on

research ethics. Authors adhere to publication requirements

that submitted work is original and has not been published

elsewhere in any language.

Competing interests

The authors declare that there is no conflict of interest that

would prejudice the impartiality of this scientific work.

Authors’ contribution

All authors of this study have a complete contribution for

data collection, data analyses and manuscript writing.

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2021, Volume 9, Issue 2, Pages: 178-182

7. Minimum requirements for infection prevention and control.

Geneva: World Health Organization; 2019. (Available at:

https://www.who.int/infection-prevention/publications/min-req-

IPC-manual/en/, accessed 20 January 2020.

Funding

“

Not applicable”

Ethics approval and consent to participate

This study was supported by Qom University of Medical

Sciences by ethic number (IR.MUQ.REC.1398.162). All

dataset analyzed during the current study is publicly available

at the Qom University of Medical Sciences.

18. WHO guidelines on hand hygiene in health care: first global patient

safety challenge – clean care is safer care. Geneva: World Health

Organization; 2009 (https://apps.who.int/iris/handle/10665/44102,

accessed 17 January 2020).

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