








key: cord-305262-23qylbmg
authors: Rowan, Neil J.; Laffey, John G.
title: Unlocking the surge in demand for personal and protective equipment (PPE) and improvised face coverings arising from coronavirus disease (COVID-19) pandemic – Implications for efficacy, re-use and sustainable waste management
date: 2020-09-10
journal: Sci Total Environ
DOI: 10.1016/j.scitotenv.2020.142259
sha: 
doc_id: 305262
cord_uid: 23qylbmg

Currently, there is no effective vaccine for tackling the ongoing COVID-19 pandemic caused by SARS-CoV-2 with the occurrence of repeat waves of infection frequently stretching hospital resources beyond capacity. Disease countermeasures rely upon preventing person-to-person transmission of SARS-CoV2 so as to protect front-line healthcare workers (HCWs). COVID-19 brings enormous challenges in terms of sustaining the supply chain for single-use-plastic personal and protective equipment (PPE). Post-COVID-19, the changes in medical practice will drive high demand for PPE. Important countermeasures for preventing COVID-19 transmission include mitigating potential high risk aerosol transmission in healthcare setting using medical PPE (such as filtering facepiece respirators (FFRs)) and the appropriate use of face coverings by the general public that carries a lower transmission risk. PPE reuse is a potential short term solution during COVID-19 pandemic where there is increased evidence for effective deployment of reprocessing methods such as vaporized hydrogen peroxide (30 to 35% VH2OH) used alone or combined with ozone, ultraviolet light at 254 nm (2000 mJ/cm2) and moist heat (60 °C at high humidity for 60 min). Barriers to PPE reuse include potentially trust and acceptance by HCWs. Efficacy of face coverings are influenced by the appropriate wearing to cover the nose and mouth, type of material used, number of layers, duration of wearing, and potentially superior use of ties over ear loops. Insertion of a nose clip into cloth coverings may help with maintaining fit. Use of 60 °C for 60 min (such as, use of domestic washing machine and spin dryer) has been advocated for face covering decontamination. Risk of virus infiltration in improvised face coverings is potentially increased by duration of wearing due to humidity, liquid diffusion and virus retention. Future sustained use of PPE will be influenced by the availability of recyclable PPE and by innovative biomedical waste management.

Since first reported as a cause of serious human pneumonia in Wuhan, Hubei, China in December 2019, the novel coronavirus COVID-19 has spread worldwide with devastating consequences. At the time of writing (29 th August, 2020), there has been 25.1 million cases of COVID-19 reported (in accordance with the applied case definitions and testing strategies in the affected countries) including 845,343 deaths (European Centre for Disease Control and Prevention, 2020) . There is evidence of resurgence of the SARS-CoV-2 globally with the emergence of second waves of infection in many countries (European Centre for Disease Control and Prevention, 2020) . Hong Kong is addressing its third wave of infections, where Australia is battling a second wave of infection having previously reduced viral transmission cases close to zero. COVID-19 has also emerged strongly in developing low-resource countries that already have significant healthcare challenges, such as across the African continent that is also challenged with Acquired Immunodeficiency Syndrome (AIDS) and Mycobacterium tuberculosis as co-morbidities (African Centre for Disease Control and Prevention, 2020) .

Currently, there is still no effective vaccine or anti-viral therapy for COVID-19 with reliance upon the prevention of transmission by way of imposing a lockdown, cocooning, social distancing, and wearing of face masks in order to protect vulnerable groups and to safeguard frontline healthcare professionals. Epidemiological studies show that social distancing prevents person-to-person transmission of SARS-CoV-2, which is relevant given that there is growing recognition that asymptomatic carriers may also contribute to this transmission (Li et al., 2020) . There is evidence to suggest that COVID-19 is a super-spreader of infectious airborne viral particles where several people can be infected at the same time (Li et al., 2020) .

publication from 1 January 2003 (as the first recorded human infection of SARS-1 occurred in November 2002 (as per Derraik et al., 2020) and 8 August 2020. Titles and/or abstracts were screened by the first author and where appropriate, full text of individual research studies, opinion pieces and reviews were consulted. Key words used were PPE; reuse;

reprocessing; disinfection; decontamination; N95; COVID-19; SARS-CoV-1; SARS-CoV-2;

UV; hydrogen peroxide vapour (VH2O2); ozone; waste management; recycling. Data extraction and rapid analysis was supplemented by conducting a short observation study where the first author noted the types of facemasks and face coverings worn by the public on entering a large shopping centre in the Republic of Ireland on 14 th and 15 th August 2020.

At the time of initial writing (3 rd April, 2020) (Rowan and Laffey et al., 2020) , the number of confirmed COVID-19 cases had reached 1 million, including 51,515 deaths, which highlights that a 25-fold increase in the prevalence of SARS-Cov-2 has occurred in only 4 months (European Centre for Disease Prevention and Control, 2020) . Rowan and Laffey (2020 had predicted an unprecedented high demand for PPE across the globe and therefore, it was prudent to consider PPE reuse as a potential option to meet the critical shortage in the supply chain for frontline HCWs. Rowan and Laffey (2020) intimated that the structure of SARS-Cov-2 is such that is sensitive to harsh environmental stresses. Moreover, the structure of SARS-CoV-2, and related coronaviruses, includes a RNA genome, a protein capsid, and an outer envelope. Viral inactivation is linked to the alteration of one of these structural elements by an environmental stress, such as, heating, ultraviolet light, and biocides (Bentley et al., 2016; Pinon and Vialette, 2018; Gorbalenya et al., 2020) . The proteins and lipids of the (Li et al., 2016) , is such that these viruses are more likely to be sensitive to disinfection technologies (Pinon and Vialette, 2018; Rowan and Laffey, 2020) . Kampf et al. (2020) had also analysed 22 studies of different human coronaviruses where SARS, MERS, HCoV (but not including were efficiently inactivated by disinfection on variety of contact surface using 62 to 71% ethanol, 0.5% hydrogen peroxide, or 0.1% sodium hypocholorite within 1 min of exposure, but survived on untreated surfaces for up to 9 days. Van Doremalan et al. (2020) also conducted tests that showed that SARS-CoV-1 remains on plastic, stainless steel, copper and cardboard for up to 72 h. These and other studies have informed selection of many current disinfection procedures to address SARS-CoV-2 pandemic, including PPE reuse.

Given that disposable, plastic-based, PPE (gowns, eye protection, gloves, face masks, filtering facepiece respirators (FFRs)) are heat sensitive, existing healthcare technologies were considered to be either not available, unsuitable or not configured for reprocessing of PPE in healthcare for emergency use (Rowan and Laffey, 2020) . However, potential solutions for effective reprocessing of PPE that considered virus inactivation, material compatibility and device functionality (filtration efficacy, penetration, fit test and so forth) post processing included use of low temperature hydrogen peroxide vapour (VH2O2), ultraviolet germicidal light (UVGI), moist heat, and use of weak bleach for liquid decontamination (Rowan and Laffey, 2020; CDC, 2020) . McEvoy and Rowan (2019) had published a comprehensive review on the background and efficacy of VH2O2 for terminal sterilization of medical devices that was used to provide supportive technical information in choice of procedures. This information was supported by prior findings of Bentley et al. (2016) who reported on 4 log 10 viral titre reductions for the recalcitrant naked Norovirus in a variety of hospital settings (stainless steel, glass, vinyl flooring, ceramic tile, PVC plastic cornering) using 30% w/w hydrogen peroxide vapour. Rowan (2019) had also reviewed potential microbial mechanistic information underpinning UV disinfection that also provided supportive foundation knowledge for the potential use of pulsed light technology for PPE.

Journal Pre-proof Information underpinning these candidate technology solutions included best-published information of efficacy of these approaches to surface disinfection cornoavirus or related viruses and surrogate biological indicator organisms on different surface materials (Kampf et al., 2020) .

The FDA had authorised use of VH2O2 technology, under emergency use authorization (EUA), for the reprocessing of critical N95 face masks in the United States in order to help address COVID-19 transmission. This was informed by Columbus-based Battelle process studies (Battelle, 2016) . Given exceptional circumstances, original equipment manufacturers (OEMs) of PPE had also suggested possible appropriate reprocessing strategies, but they also reiterated that their products had been manufactured with the sole intention of single use. The contingency plan to be adopted in hospitals on the west of Ireland was to procure, install and seek approval from competent authority for the deployment of VH2O2 (Bioquell BQ50 system) for filtering face-piece respirators (FFRs) and surgical gowns, UV technologies (NanoClave low-pressure UVGI system and Claranor Pulsed Light system) for simple PPE such as face shields, and use of mild sodium hypochlorite (4000ppm) for liquid decontamination of critical Starmed hoods. The VH202, UVGI and mild liquid disinfection strategies have been set up, but there remains a requirement to gain trust and confidence by HCWs for PPE reuse post treatments.

Several authors have reported on the viability of SARS-CoV1 and SARS-CoV-2 on various contact surface such as printed paper, printed tissue, cloth, wood, glass, banknotes, plastic, stainless steel, surgical mask layers over different environmental temperatures, relative humidity and durations (Li et al., 2003; Lai et al, 2005; Pagat et al., 2007; Chan et al., 2020; Chin et al., 2020; Fischer et al., 2020; Kasloff et al., 2020; Behzadinsaab et al., 2020; Biryukov et al., 2020) . In general, lower environmental temperatures support the longer survival of SARS-CoV-2 on materials as reported by Chin et al. (2020) where only a 0.7 log 10 reduction was observed for SAR-CoV-2 at 4°C after 14 days compared with 4.5 log 10 reduction at 22°C (room temperature) after 14 days and 4.5 log reduction at 37°C after just 2 days. Similarly, also noted only a 2 log 10 reduction of SARS-CoV-1 at 4°C after 14 days when the virus was inoculated onto glass surfaces. The longer survival of SARS-CoV-2 at colder temperatures may have future implications for viral persistence on contaminated face coverings as we are approaching the winter flu season.

However, public health practices that have been put in place to mitigate the spread of SARS-CoV-2 are likely to have a positive impact on the occurrence of influenza cases given that these viruses share similar modes of transmission to cause illness. Derraik et al. (2020) comprehensively reported on the viability of SARS-CoV-1 and SARS-CoV-2 on different contact surfaces, without and with UV or heat treatments, and noted the importance of virus load and inoculum size on inactivation performance. Lai et al. (2005) , who looked specifically at PPE, highlighted the variability in SARS-CoV-1 viability of 2 days on a disposable polypropylene gown and 24 h on a cotton gown for same 6 log 10 reduction. Akin to studies reported by Derraik et al. (2020) , we also observed that the majority of researchers used medium tissue culture infective dose (TCID 50 ) to report inactivation of SARS-CoV-1 and SARS-CoV-2 on various surfaces. Kasloff et al. (2020) (Rowan and Laffey, 2020) . There is also a pressing need to explore attitudes, perceptions and possible barriers for use of reprocessed PPE by frontline clinicians and nurses that would entail conducting a social marketing study so as to inform overall acceptance and to overcome behaviour change factors for PPE reuse.

Increased use of face masks by people in communities in Irish society is aligned with similar recommendations in other countries across the globe (Rubio-Romero et al., 2020; Holland et al., 2020; Jansson et al, 2020) . WHO (2020) also advocate that "use of face masks alone are insufficient to provide adequate level of protection, and other measures should also be adopted". WHO (2020) also advises for each country to apply a risk-based approach that considers benefits (such as reduction of potential risk of exposure), along with potential risk (such as self-contamination, false sense of security, impact of PPE shortage) when deciding to use facemasks by general population. The Centre for Disease Control and Prevention (2020) A short observational study of the types of face masks and face covering used by 1043 shoppers as they entered a large retail centre was conducted in the Irish midlands on 14 th and 15 th August, 2020. Findings revealed that 461 wore coverings with ear loops, 320 wore procedural masks with elastic ear loops, 140 wore KN95/N95 respirators, 38 wore face shields, 5 wore bandanas, 3 wore scarfs, and 56 shoppers did not wear face coverings. There was no evidence of anyone using surgical masks secured with ties. It was observed that 64 appeared to be wearing face masks or coverings over their mouth only, or below their chin, or J o u r n a l P r e -p r o o f

were improperly fitting such that these did not cover the nose or mouth. Some shoppers removed their face masks, or raised their face shields to the top of their head, in order to have conversations, which indicated a lack of understanding of their purpose and function. Recnet evidence from Fischer et al. (2020) with FFRs suggests that face masks and face coverings should consider use of adjustable cloth ties, as this design potentially offers better filtration efficacy of the virus compared to using a face coverings that have elasticated ear loops.

Creativity in the design of cloth coverings was observed including insertion of a clear panel to facilitate lip reading. Face cloths are likely to be disinfected through use of domestic washing machine for re-use where combination of moist heat above 60°C and detergent will kill COVID-19 Rubio-Romero et al., 2020) . . CDC (2020b) report that it is not known if face shields provide any benefit as source control to protect others from the spray of respiratory particles. CDC does not recommend use of face shields for normal everyday activities or as a substitute for cloth face coverings. If face shields are used without a mask, they should wrap around the sides of the wearer's face and extend to below the chin. (CDC, 2020; Rowan and Laffey, 2020) .

Some studies have been reported on the use of different regimes of heating for PPE processing. Heating causes irreversible structural damage in virus proteins that prevents binding to host cells (Derraik et al., 2020) ; the challenge is for thermal procedures is to eliminate SARS-CoV-2 with damaging PPE. The guiding principle, similar to the concept of pasteurization for use with heat sensitive foods, is that one can achieve a similar one-log reduction in viral load by reducing exposure time with increasing temperature. For example use 72°C for 15 seconds provides similar level of lethality to that of using a holding temperature of 60°C for 30 min. In general, heat treatment at 60°C for 30 min would lead to ca 4.6 to 7 log 10 reduction in SARS-CoV-2 (Table 1) . However, doubling exposure duration at 60°C to 60 min would be prudent given the variability in heat inactivation studies reported J o u r n a l P r e -p r o o f for SARS-CoV-1 and SARS-CoV-2 (Derraik et al., 2020) . For example, Darnell and co-workers (2004) reported on residual infectivity after exposure of SARS-CoV-1 to heating at 65°C for 90 min. Also, there is considerable variability in the manner by which the viruses have been tested by researchers that includes use of artificial solutions, surfaces and materials, with and without soiling, where the lack of harmonized procedures makes it challenging to appreciate significance of findings and relevance to practice, such as PPE (Table 1) . Variable factors influencing the efficacy of heat inactivation procedures for SARS-CoV-1 and SARS-CoV-2 include number of viruses present (viral load), presence of organic matter (soiling), temperature, humidity and duration of treatment (Table 1) .

Song and co-workers (2020) reported on the use of heating of face masks in an oven at 56°C

for 30 min combined with hot air from a hair dryer for 30 min to inactivate influenza virus without observing efficacy in filtering capacity. Rubio-Romero et al. (2020) noted that findings from this particular study was used by the International Medical Centre of Beijing (2020) 

FFRs maintain their filtration efficiency after decontamination at 70°C for 30 min, although fit and deformation testing is not reported. Price and Chu (2020) and Spanish Society of Preventive Medicine, Public Health and Hygiene (2020) recommend use of dry heat at 70°C

for 30 min in a convection oven to ensure constant and uniform temperature maintenance.

However, there is a general lack of information on the effect of dry heat on filtration, fit-test or deformity over several decontamination cycles (N95DECON, 2020; Rubio-Romero et al., Derraik et al., 2020) .

The CDC (2020) stated that, based on limited research available as of April 2020, moist heat has shown promise as a potential method to decontaminate FFRs. The CDC's National Institute for Occupational Safety and Health (2020) reiterated that before using any decontamination method, it should be evaluated for its ability to retain 1) filtration performance, 2) fit characteristics achieved prior to decontamination, and 3) safety of the FFR for the wearer (e.g. by inactivating SARS-CoV-2). Moist heat, consisting of 60°C and 80% relative humidity (RH) caused degradation in the filtration and fit performance of tested J o u r n a l P r e -p r o o f FFRs [Berman et al., 2010; Bergman et al., 2011; Viscusi et al., 2011] . Heimbuch et al. (2011) disinfected FFRs contaminated with HINI influenza using moist heat of 65°C and 85% RH that achieved a minimum of 99.99% reduction in the test virus. CDC (2020) noted that one limitation of the most heat method is the uncertainty of disinfection efficacy for various pathogens. This is particularly relevant as there could be more than one respiratory virus or pathogen on contaminated FFRs in healthcare environment and during COVID-19 pandemic.

Ozone can disrupt lipids and proteins in the cell envelope of viruses exposing vital genetic material, thus causing oxidative inactivation (Rowan, 2019) . Zhang et al (2004) had previously reported on decontamination of FFP respirators using ozone where SARS-CoV1 was inactivated using different concentrations of ozone solution disinfection with efficacy at 27.73 mg/L for 4 min exposure., Toon (2020) also described the efficacy of ozone for decontaminating PPE where the relative humidity needed to be maintained above 50%, Dennis et al. (2020) reported virucidal potentialof ozone where they implemented a simple disinfection-box system for treating FFRs. The authors recommended ozone concentrations at 10 to 20 ppm combined with an exposure of at least 10 min. Dennis et al. (2020) note advantages of ozone that include rapid virucidal action that is effective for fibrous material, which included addressing crevices and shading. However, there is very limited information on ozone for broader PPE and medical device treatment due possibly to risk associated with its volatility.

The majority of authorised approaches advocated by competent bodies deploy hydrogen peroxide vaporization (VH2O2) for emergency reprocessing of PPE where there is critical shortage (Table 1) . Jatta et al (2020) Rowan and Laffey, 2020) . The background and benefits of using VH2O2 as a reprocessing agent or sterilising modality for medical device application have been comprehensively reviewed by McEvoy and Rowan, 2020. However, VH2O2 compatibility with cellulose-based materials in PPE needs consideration .

Grossman et al. (2020) noted that several VH2O2 sterilisation systems are currently approved for use under Emergency Use Authorization (EUA), but these technologies can be difficult to obtain due to the significant demand around the world. Grossman and co-authors (2020) described the VH2O2 process (closed and sealed off room using Bioquell Z-2 disinfection cycle) for N95 respirators. These FFRs had been placed in Tyvck pouches where the process includes conditioning, gassing, dwell, and aeration of the VH2O2. Grossman and co-workers (2020) demonstrated a reproducible and scalable process for decontaminating N95 respirator within a large academic hospital and healthcare system.

The CDC (2020) all phages which was below the limit of detection. Viscusi et al. (2009) found that 9 FFR models (three particulate N95, three surgical N95 FFRs and three P100) exposed to one cycle J o u r n a l P r e -p r o o f of VH2O2 treatment using the STERRAD 100S H2O2 Gas Plasma Sterilizer (Advanced Sterilization Products, Irvine, CA) had filter aerosol penetration and filter airflow resistance levels similar to untreated models; however, Bergman et al. (2010) found that three cycles of gas plasma treatment using the STERRAD 100S H2O2 Gas Plasma Sterilizer negatively affected filtration performance. Table 1 lists the most frequently published papers on the decontamination of reuse of PPE using VH2OH.

The CDC (2020) reported that ethylene oxide (EO) is not recommended as a decontamination method for FFRs as it is carcinogenic and teratogenic and may be harmful to the wearer, even at very low concentrations. NIOSH set a low exposure limit due to residual cancer risk below the quantitative limits of detection, i.e, preferring lowest feasible exposure (CDC, 2020). The CDC reviewed several studies where EO was shown to not harm filtration performance for the 9 tested FFR models. All tests were conducted for one hour at 55°C with EO gas concentration ranging from 725 to 833 mg/L Viscusi et al., 2009; Bergman et al., 2010) . Also, six models that were exposed to three cycles of 736 mg/L EtO all passed the filtration performance assessment (Bergman et al., 2010) .

Ultraviolet (UV) irradiation causes inactivation of viruses by damaging RNA or DNA via a photo-dimerization process (Darnell et al., 2004 The CDC (2020) also noted that ultraviolet germicidal irradiation (UVGI) is a promising method for PPE reuse, but stated that not all UV lamps provide the same intensity, thus treatment times would have to be adjusted accordingly (Table 2) . Moreover, UVGI is unlikely to inactivate all the viruses and bacteria on an FFR due to shadow effects produced by the multiple layers of the FFR's construction. The CDC (2020) noted that acceptable filtration performance was recorded for eleven FFR models exposed to various UV doses ranging from roughly 0.5-950 J/cm 2 and UVGI was shown to have minimal effect on fit. Card et al. (2020) reported on the potential efficacy of FFP respirator decontamination using UVGI using biosafety cabinets that describes irradiation for 15-20 min per side with a fluence of 100 W/cm 2 . Lowe et al. (2020) (2020) also advocates against use of UV disinfection of filtering facepiece respirators due to "shadowing effects produced by the multiple layers of the filtering respirators construction". Rubio-Romero et al. (2020) noted that the advantages of UV could be that  J/cm 2 of UV-C inactivates viruses similar to SARS-CoV2 on N95s that maintain fit and filtering performance after 10-20 cycles but shadowing may affect disinfection efficacy (N95DESCON, 2020c). Straps also become degraded after multiple cycles of UV (Mills et al., 2018) . Table 3 .

There has been a staggering increase in the production of ventilators and supply of single-use PPE to meet unprecedented demands globally (Health Products Regulatory Authority, 2020;

Global News Wire, 2020). Cocking (2020) (2020) platforms that will meet need for accelerate rate of usage so as to ensure no undue risks aligned with bringing together multi-actors, particularly competent authorities/regulators.

There is a commensurate need for an understanding of the appropriateness and impact of different reprocessing modalities on materials when considering future reprocessing of PPE and medical devices (Rowan and Laffey, 2020) .

There is an unprecedented surge in plastic-based PPE usage, arising a s consequence from the ongoing COVID-19 pandemic, which constitutes a new form of single-use-plastic (SUP)

waste that will to plague our oceans posing a threat to our marine ecosystems (Euronews, 2020) . Shorelines have been littered with discarded PPE, such as masks and visors, with the gullets of birds stuffed with latex gloves, along with crabs tangled in face masks. Marine conservation organisation OceansAsia highlighted the growing number of single-use face masks being discovered during its plastic pollution research in the Soko Islands near Hong

Kong (Clark, 2020) . To provide context, Republic of Ireland is a small country with a population of ca 4.5 million, yet it's HCWs require 9 million face masks per week at a cost to the exchequer of €1billion a year (Farsaci, 2020) . Nzediegwu and Chang (2020) . The World Health Organization (2020) projected that supplies of PPE must increase 40% monthly to deal effectively with COVID-19 pandemic. Essential PPE includes an estimated 89 million medical masks, 76 million pairs of medical gloves and 1.6 million pairs of goggles. The increased demand for PPE is expected to be sustained beyond COVID-19 with an estimated compound annual growth of 20% in facial and surgical masks supply from 2020 to 2025 . It is noteworthy that

China produced 240 tons of medical waste daily during peak of pandemic in Wuhan (Singh et al., (2020) . Horton and Barnes (2020) reported that microplastics have now been found in the most remote places on earth, far away from human activities. In addition with climate-induced stress, microplastics may lead to enhanced multi-stress impacts, potentially affecting the health and resilience of species and ecosystems. The impact on PPE contamination on the marine environment has yet to be determined where there is significant gaps in knowledge. Indiscriminate use and inappropriate disposal or mismanagement SUPs that have low biodegradation have led to accumulation of plastic debris in terrestrial and aquatic ecosystems globally . This will affect natural biota, agriculture, fisheries along with threatening human and animal health (Jambeck et al., 2015) .

Despite recent progress made in plastic sustainability and waste management, Silva et al. (2020) have noted widespread drawbacks in the use and management of plastics in the fight against COVID-19 pandemic that area associated with government imposed partial and total lockdown of cities/regions/municipalities that has promoted greater use of SUPs, including PPE, by the general public and healthcare workers (Tobías, 2020) . There has also been a shift towards mandatory use of PPE by the general public, along with frontline healthcare workers J o u r n a l P r e -p r o o f where Silva et al. (2020) noted that over 50 countries are mandated to wear masks in public places. There is also a commensurate need for increased production of PPE globally. World

Health Organisation (2020) had expressed concerns about use of masks by general public due to lack of correct handling, and disposal, and the shortage of this material in healthcare materials. Silva et al. (2020) noted that surgical masks should not be worn longer than a few hours (such as 3 h) and should be appropriately discarded to avoid cross-contamination (i.e., in a sealed plastic bag). However, incorrect disposal of PPE is widespread and has been found in several public places and natural environments NGO Oceans Asia, 2020) . observed that masks are likely to degraded into smaller microplastic pieces as are made from nonwoven materials (e.g., spunbond and meltdown spunbond) often incorporating polypropylene and polyethylene. These authors also noted that significant enhancement in the usage of PPE and other SUPs is likely to result in an overload increase in waste generation that would disrupt viable options for effective waste management. Many countries have classified all such hospital and household waste potentially contaminated with SARS-CoV2 as infectious that should be incinerated under high temperature (ensuring sterilization), followed by landfilling of residual ash (European Commission, 2020; Silva et al., Ilyas et al., 2020) . Ilyas and co-workers (2020) reviewed, and reported on the merit, of developing different disinfection technologies for handling COVID-19-generated waste from separate collection to using various physical and chemical steps with view to reducing health and environmental risks.

There is also a significant void in communication channels to general public about appropriate disposal of used face-masks and gloves during COVID-19 that may require user behavioural change, such as exploiting health belief model through social marketing approaches (Suanda et al, 2013; Suanda et al., 2017) . However, Silva et al. (2020) noted that not all countries are capable of managing such waste appropriately and are been forced to use

direct landfills or open burning as alternative strategies. There is also commensurate concerns about the short, and more longer term, impact of burning considerable amount of plastic that may increase environmental footprint due to release of GHGs and undesirable J o u r n a l P r e -p r o o f hazardous compounds . As some items of PPE are lightweight, there is potential for them to be blown by wind to pollute natural environments including threatening terrestrial and aquatic biota, such as by entanglement. Silva et al. (2020) noted that up 40,000 kg of masks may find their way inappropriately into the natural environment arising from WWF (2020) reporting of inappropriate disposal of only 1% for over 10 million masks introduced to the environment monthly. In order to allay environmental problems arising from COVID-19 due to high demand on SUPs and PPE that produces increased medical waste, Silva et al. (2020) advocated (1) 

In the short term, it is important to maintain the PPE supply chain in order to the ensure health and safety of our citizens and our frontline HCWs. However, we now need to look at contingency planning in order to future proof against the potentiale environmental impact of increased single-use plastic (SUP) PPE waste using sustainable solutions. Opportunities will arise to address this challenge through seamlessly connecting research and entrepreneurial ecosystems that will generate a new pipe-line of potentially usable bioplastic products. This could be accelerated through multi-actor innovation hubs linked to healthcare, industry and academia (Rowan and Galanakis, 2020) . Silva et al. (2020) noted that the replacement of plastic value chain from fuel-based raw materials and energy has been priorities, which features in many international agreements addressing a green and circular economy. Silva et al. (2020) also noted that bio-based plastics supports are emerging, but at an early stage capturing a market share of ca. 2% due mostly to low-cost of fossil-based J o u r n a l P r e -p r o o f plastics, the intense requirement for land use and related financial investment, and undeveloped recycling and/or disposal routes.

Hatti-Kaul et al. (2020) described screening for microbial strains for enhanced hydrolytic and biodegradation abilities for direct conversion of biomass (such as microalgae), extraction of value-added products, and synthesis (polymerisation) process. However, such potentially high-performance bio-based polymers, similar to physical properties of fossil fuel-counterparts (such as low degradability, high durability) , would need to be characterized and tested for suitability to match design specifications of future PPE including tolerance to thermal processing and potential re-use. OEMs of PPE, academia and regulators should play as strong role in informing the efficacy of bio-based reusable polymers for next-generation products that considers suitability from design, safety and life cycle assessment perspectives. End-of-life strategies need to be consider for waste management and recycling of PPE during COVID-19 used by general public without compromising on safety, where landfill and waste-to-energy should be a last resort option .

The rapid accumulation of plastic waste is driving international demand for renewable plastics with superior qualities (e.g., full biodegradability to CO 2 without harmful by-products), as part of an expanding circular Bioeconomy (Karan et al., 2019). There has been increasing interest in the identification of alternatives to petroleum-based plastics for various industrial applications where desirable bio-based material properties would include ease of biodegradation and renewability (Emadian et al., 2016; Thakuv et al., 2018) .

Bioplastics partly or wholly made from biological materials, and not crude oil, represent an effective way of keeping the huge advantages of conventional plastics but mitigating their disadvantages (Carbon Commentary, 2011) . A bioplastic is a plastic that is made partly or wholly from polymers derived from biological sources such as sugar cane, potato starch or the cellulose from trees, straw and cotton (Thakuv et al., 2018) . There presents an opportunity to exploit the 9 stages of technology readiness developed by NASA (Straub, 2015) to evaluate the sustainability and maturity of emerging innovations for COVID-19 that also addresses environmental friendliness as well as functionality. This strategy is particularly relevant as it address potentially sustainable products from conceptualisation to commercial deployment at higher technology readiness levels: this is particularly relevant given that industry would be familiar with this concept and would allow ease of transitioning for environmental impact. This evaluation of new bioplastics could include life cycle (Ruiz-Salmón et al., 2020) and ecotoxicological (Garvey et al., 2015) assessments of different trophic levels reflecting impact on biodiversity that connects academia with industry partners and policy makers. O'Neill et al. (2020) described development of freshwater aquaculture on cutaway peatlands using organic principles where vast quantities of microalgae, used as natural means of water quality waste remediation, could be used as test system for advancing bioplastic-based PPE innovation and recycling for circular economy developments. Future green innovative research could be extended to new biopolymer-based wrapping and packaging (including for adjacent food industry) to investigate non-thermal treatments that encompass both complex viruses and parasites . A limiting factor in the production of alternative biomaterials for alternative to single-use PPE relates to thermal stability of materials for fabrication and potential for deformation due to thermal processes. Skrzypczak et al. (2020) recently reported on a new 3D printing approach for meeting such a need where they J o u r n a l P r e -p r o o f described an affordable, self-replicating, rapid prototyper that would also make this approach more accessible to home-based 3D printing activities. also demonstrated potential for exploiting different forms of polymer processing (such as 3D printing and injection moulding) after novel vapour hydrogen peroxide and electron beam treatments that could be advance next-generation PPE and medical device technologies.

In response to meeting threats of COVID-19, there is substantially increased volumes of medical waste produced that also contains PPE, which presents unprecedented challenges for meeting effective waste management strategies globally with significant potential for overload of systems Want et al. 2020 . have noted that the unprecedented demand has also impacted other industries reliant upon PPE including manufacturing, construction, oil and gas energy, transportation, firefighting and food production. also noted that this pandemic has substantially impacted upon how solid-waste management activities are performed as prior to COVID-19 resource recycling and waste management were not regarded as essential services and were placed in lockdown. However, the strategically important disease mitigation role of waste management has been recognised given the need to properly dispose and handle SARS-CoV2 contaminated waste to avoid transmission (Reuters, 2020; Price et al., 2020) .

Wastes and their Disposal has urged countries to treat waste management amid COVID-19 as urgent and essential public service. These authors noted that PPE includes plastics as major constitutes representing ca 25% by weight, which if not recycled or their disposal may contribute substantially to hazardous environmental pollutants, such as dioxins or toxic metals. Polypropylene is a common constituent of PPEs, such as found in N95 masks, Tyvek protective suits, gloves, and medical face shields. Singh and co-workers (2020) also noted that the potential for recovery of polymers from mixed healthcare waste including PPE is challenging. This would be further influenced by the low-level of recycling worldwide and lack of government policies. noted that single-use PPE is not a sustainable that are easier to maintain are preferred in China. Incineration is widely deployed as is deemed to be safe, simple and effective (Ghodrat et al., 2017) where extreme high temperatures completely kill microorganisms along with converting organic matter into inorganic dust. However, hospitals vary in type of incineration approach depending upon waste preparation and flue gas purification that includes pyrolysis vaporization incinerator where organic components of waste are converted to flammable gases to avoid dust at temperatures above 850°C that reduces particle emission to air. report that these high temperatures is conducive to complete destruction of toxic and hazardous components, thereby reducing production of toxic pollutants such as dioxins due to low temperature combustion (Zhu et al., 2008 Wang et al., (2020) described chemical disinfection technologies for treatment of hospital waste that is typically used in combination with mechanical and crushing treatments in China.

Generally, crushed hospital waste are mixed with chemical disinfections such as sodium hypochlorite, calcium hypocholorite, chlorine dioxide for fixed contact times during which organic wastes are decomposed and microbial threats inactivated. Chemical disinfection have desirable attributes including low effective concentrations, rapid action, stable performance and broad sterilisation efficacy for different types of microorganisms. These chemical disinfectants are generally used as are non-corrosive, safe, easily soluble in water but not easily affected by chemical or physical factors with low toxicity and reported to have no residual hazard post disinfection (Chen and Yang, 2016) . suggest that chemical disinfection technology could be considered when amount of waste is small. also reported on use of microwave disinfection as a means of energy saving, low action temperature, slow heat loss, light damage and low environmental pollutions with no residues or toxic wastes after disinfection, but requires strict control by special microwave devices. stated that microwave technology only used at present for treatment of biohazardous wastes, but the technology is been promoted as effective supplementation technology for incineration to enable diversification of hospital wastes in China. Wang also reported that microwave technology can achieve logarithmic value for killing complex pathogens such as parasites and viruses at > 6 log along with killing J o u r n a l P r e -p r o o f of Bacillus subtilis endospores at > 4 spores. also reported on high temperature steam disinfection (saturated water vapor with temperatures greater than 100 C) to kill microorganisms (Zhang et al., 2016) . In China, a log kill of thermophilic lipobacillus endospores at > 5 logs is required. However, this approach has a low volume reduction rate and easily generates toxic volatile organic compounds during disinfection (Teng et al., 2015) .

From perspective of investment and operation costs, as well as economic and social benefit, high temperature incineration is still most popular approach to hospital waste disinfection in China. Thus, there are pressing needs to define effective decontamination strategies for medical waste through appropriate management strategies will also contribute to global collective effort in reducing SARS-COVID-19 transmission along with future safeguarding our environment.

There is extraordinary pressure to meet shortages in single-use PPE supply for our frontline clinicians and healthcare workers. PPE treatment is challenging as the constituent material, including single-use plastics (SUPs), are sensitive to harsh decontamination processes.

There has been an unprecedented surge in the production of commercial and homemade cloth and fabric face coverings to offset this challenge and to help with preventing person-to-person transmission in the community setting. Many countries across the globe are extending, decontaminating and reusing PPE where there is critical shortage for frontline healthcare workers (HCWs), but under emergency use only. This unprecedented need will continue given the absence of a vaccine and occurrence of successive waves of SARS-CoV-2 globally; and, the likely high demand for PPE by the medical and nursing profession beyond COVID-19. Fischer, E.P., Fischer, M.C., Grass, D., Henrion, I., Warren, S. W., Westman, E. (2020) . Low cost measurement of facemask efficiency for following expelled droplets during speed . 

Zhao et al.

[N95s]

Liao et al. 

Sickbert-Be nnett et al. 

Perencev ich et al.

Rubio-Ro mero et al (2020) Dangaville et al. (2020) [shortage]

Saini et al.

[overalls]

Barceló (2 020) Virkram et al. 

Derraik et al.

Fisher and

Shaffer (2011 ) Ma et al.

O'Hearn et al. 

Grinivas an and Peh (2020) Lowe et al. 

Mullerji et al. (2020) Ahmed et al.

European Commissi on (2020 Schwart z et al (2020) Inagalei et al (2020) [DUV-LEDs] Toon (2020) [Ozone]

MacIntyre et al.

Boṧkoski et al. (2020) Matin-Rodri guez et al (2020) [pain] 

[N95s]

(2010) (2020) FDA (2020c)

Laffey (2020) Rubio-Ro mero et al. 

MacKenzi e (2020) [Househol

MacIntyre et al (2015) Toon (2020) [Gowns]

Clark (2020) Jatta et al (2020) Liao et al (2020) Batejat et al ( FDA (2020 Park (2020) 

Ou et al.

Laffey (2020) [Surgical 

Toon (2020) [Ozone]

Ou et al. 

Ou et al.

Barceló ( 

Ozog et a.

Daeschler (2020) Perkins et al.

Heilingloh et al., (2020) Pastorino et al. Genus, species and strain of microorganism *Provide appropriate culture collection reference number and/or include type strain for test microorganism(s) in studies *Include Bacillus atrophaeus and/or Geobacillus stearothermophilus endospore along with test organisms *Confirmation of identify of test microorganisms by biochemical, physiological, morphological, immunological and/or molecular means (provide name of supplier for rapid test kits) *Method of storing cultures (cryoprotectant) and frequency of sub-culturing (using fresh microbial slope every month kept at 4°C where bacterial indicators used) Initial inoculum * Description of procedures for microbial cultivation including name of supplier company for media (to include in vitro analysis) * Growth medium composition, growth temperature, pH, incubation time, and growth phase (exponential or stationary) * Growth achieved under static or orbital cultivation (rpm) * Confirm purity by identifying 3 randomly selected isolates Recovery conditions and enumeration methods for test strains * Composition of media used for recovery to include basal media or physiological saline as diluent * Time and storage conditions between treatment and microbiological analysis * Description of procedure for enumerating viral test strains post treatments, such as use of in vitro tissue culture procedures UV treatment medium properties and conditions For commercial: description of power unit used for generating pulses to include equipment name of the supplier company and model For prototype: adequate description of components including treatment chamber, electrical configurations and specifications Auxiliary devices - * Temperature probe * Thermophile power detector and software for total broad-spectrum dose received by sample * Transmissivity sensor to monitor %UV transmittance Ensure microbial population density is ≤ 5-log orders to mitigate against influence of protective shading effects Include description of media composition, pH, aw J o u r n a l P r e -p r o o f Composition of menstruum used as diluent for treated samples Sufficient number of treatment trials and replications to provide statistical confidence of findings at 95% level; description of statistic test and version of software package (such as Minitab or SPSS) Description of method used to generate bacterial endospores (natural aged for 7 days or incorporation of manganese sulphate to expedite conversion of vegetative cells to spores on agar surfaces) Include native microflora along with artificially seeded test microorganisms due to variability in resistance profile to PL Consider occurrence of cavities in plant surface microstructures that may protect microorganisms from incident light due to shading As part of EUA, the FDA (2020) reviews the totality of scientific evidence for PPE reprocessing including specialist testing *testing submitted within previous applications supporting device clearance for other uses that considers different types of polymer materials, such as materials consistent with those found in compatible N95 respirators. *performance data such as sporicidal test, residual analysis, bioburden reduction validation demonstrating > 3 log reduction of a non-enveloped virus challenge; testing regarding material compatibility, functionality and filtration performance of compatible N95 respirators after multiple decontamination cycles *testing regarding residuals after decontamination of compatible N95 respirators. *Typically, reprocessed PPE are discarded after 10 treatments as per respective factsheet for facilities and personnel furnished to FDA J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f Barriers to reuse of PPE by healthcare workers include lack of knowledge to inform acceptance and discomfort over prolonged usage with potential for social marketing studies to inform trust and associated decision making Rimmer (2020); Mitchell (2020) Evaluation of fitted filtration efficiency (FFE) showed that surgical masks with ties (71.5±5.5%) and procedural mask with ear loops (38.1±11.4%) exhibit lower FFE post VH2O2 treatment is lower than N95 respirators (98.5±0.4%). This suggests potential benefits of using head ties instead of ear loops for homemade face coverings and would help prevent slippage below nose during wearing.

Sickbert-Bennett et al., 2020

Disinfection performance studies for evaluating PPE reuse over single or several cycles use surrogate viruses or bacterial endospore indicators (bioburden typically at or below 10 6 ), where most SARS-COV-2 strain(s)are studied using in vitro tissue culture infection models. Most researcher won't have access to level 3 containment facilities Rowan and Laffey, (2020) ; Derraik et al.,

Evaluation of facemask and variety of commonly available non-certified face coverings for filtering expelled droplets during speech, sneezing and coughing revealed that variability from below 0.1% (fitted N95 mask) to 110% (fleece mask). Sequence of decreasing efficacy N95 respiratory, combining cotton-polypropylene-cotton mask; combining layer cotton in pleated style mask; combining 2 layer cotton with pleated style mask; use of single layer cotton masks; knitted masks; double layer bandana; and fleece.

Fischer et al., 2020

Improvised face masks and face coverings should be used as a last solution and for low risk situation as increased duration of wearing may increase risks of virus infiltration due to humidity, liquid diffusion and virus retention European Centre for Disease Prevention and Control (2020) Use of common washing machine (ca 60°C for 30 min) combined with use of spin dryer appear effective for face cloth decontamination and reuse Zhao et al. (2020) ; Rubio-Romero et al. (2020) ; HSE, (2020) SARS-COV2 is sensitive to commonly-used disinfectants on surface. However, lower environmental temperatures promote longer survival on surfaces, which may influence efficacy of mask Derraik et al., (2020) J o u r n a l P r e -p r o o f

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β-Glucan extracts from the same edible shiitake mushroom Lentinus edodes produce differential in-vitro immunomodulatory and pulmonary cytoprotective effects -Implications for coronavirus disease

No shortage of surgical masks at the beach

Coronavirus (COVID-19) highlights. Retrieved on

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PPE is designed for single-use for medical/nursing staff, but supply chain has been insufficient to meet global needs with many countries adopting reuse practices post deployment of technologies to meet emergency COVID-19 use Rowan and Laffey (2020) ; Derraik et al., (2020) There are limited technologies suitable for PPE reuse that reflects matched efficacy for reprocessing Rubio-Romero et al. (2020) Differences in priority usage and decontamination technologies between higher risk medical environment (PPE) and lower risk community settings (face coverings) that have informed selection of technologies and approaches used Derraik et al. (2020) Evidence that PPE can be effectively reprocessed using technologies not readily available to public such as VH2O2, O3, low pressure UVC such as UVGI (2000 mJ/cm 2 ) where variance in determining efficacy of UV dose between UV modalities influencing harmonious acceptance). Generally, is greater disinfection using UVA over UVB and UVA.Derraik et al., (2020) ; Rowan, 2019; Rubio-Romero et al. (2020) High throughput VH2O2 can effectively disinfect, for example ,2,500 N95 respirators per 12 h shift at 3000-750 ppm hydrogen peroxide Rubio-Romero et al., (2020) Mackenzie, (2020); Perkins (2020) Recommendation for wearing of face masks and coverings to prevent spread of COVID-19 CDC (2020); Ministry of Health Spain (2020); Choice of technologies for reprocessing of PPE healthcare depends on the type and complexity of PPE (functionality, fit test, deformation, filtration efficacy) that are typically single use and thermally-sensitive with increasing challenges in the order face shields, gowns, FFRs (including disposable N95 respirators,) Derraik et al., (2020) ; Rubio-Romero et al. (2020) Evidence of extended use of N95 respirators such as 4 h (France, New Zealand and Sweden) to 40 h (Mexico) Kobayashi et al. (2020) Physical irradiation technologies (gamma) and ethylene oxide (EO) are not appropriate for PPE reuse due to non-compatability with material composition or concerns over lingering residual toxic end-points produced during EO Rowan and Laffey (2020) J o u r n a l P r e -p r o o f wearing such as over winter flu season Face shields are inferior to use of face masks where the latter is particularly relevant for combined use in healthcare settings to prevent infection through the eyes. Rowan and Laffey, (2020) An increasing trend towards development of smart coatings on materials for inactivation of SARS-CoV-2 and against other future potential pandemic viruses, along with provision for incorporation in PPE, mobile phones and so forth Behzadinasab et al. 2020 .Over 50 countries are now recommending facemasks by public that presents a new form single-use plastic waste Silva et al., 2020 Influence of soiling on critical PPEup to 14 days survival and retention of SARS-CoV-2 on surgical gowns. Kasloff et al., 2020. There are opportunities for innovation in new bioplastic-based PPE and waste management as there is likely to be a high demand for PPE post COVID-19 Ilyas et al., 2020 There is an increase trend towards modelling recovery scenarios to investigate the potential impact of lockdown duration that is implemented to protect frontline HCWs against COVID-19 that may include provision for PPE costings against the cost associated with medical staff absenteeism or illness due to inadequate PPE. Guan et al. (2020) ; Thomas et al. (2020) ; Ivanov et al. (2020) ; Mukerji et al. 2017) Use of artificial intelligence and deep learning could help identify high-risk patients and suggest appropriate types and use of PPE Boṧkoski et al., (2020) J o u r n a l P r e -p r o o f

The authors declare that they have no competing or conflict of interests.J o u r n a l P r e -p r o o f

