INTERNATIONAL JOURNAL OF SANITARY ENGINEERING RESEARCH volume 11 | number 1 | december, 2017 www.institut-isi.si SA N IT A R N O I N ŽE N IR ST V O  I N TE R N AT IO N A L JO U R N A L O F SA N IT A R Y E N G IN E E R IN G R E SE A R C H  V ol . 1 1  N o. 1  D ec em be r 2 0 1 7  International Journal of Sanitary Engineering ResearchVol. 11  No. 1/2017 1 “Healthy citizens are the greatest asset any country can have.” Dear readers of International Journal of Sanitary Engineering Re- search (IJSER). In front of you is 2017 issue. The author of the sen- tence above (in the title) is Winston S. Churchill. Although he was not public health or environmental health professional he made a good point. And his sentence is a ground basis which combines topics pub- lished in the current issue of IJSER. First of all I am glad and honoured to welcome new members on board of our Journal. During this year Bryan W. BROOKS, from Baylor University (Texas, USA), Graeme MITCHELL from Liverpool John Moores University (United Kingdom) and Helen UDRAS from Tartu Health Care College (Estonia) have joined editorial board of IJSER. The current issue contains six papers covering different fields of pub- lic and environmental health field. Indoor environmental quality in Slovenian children day-care centres is elaborated by Pajek et al. It is worrying that poorer situation was identified in renovated and newly constructed low-energy buildings if compared two older ones. The re- sults of both papers submitted by Pajek et al. represent an important contribution to the assessment of indoor environmental quality in the context of building construction and renovation. Use of a nudge tool for improving hand hygiene in a nursing team was studied in another type of institutional setting – in home for elderly people. Results demonstrate that after a specific change in the envi- ronment, hand hygiene improved among observed group of health workers. This is showing that nudging may help us prevent and con- trol healthcare-associated infections. Maestro et al. evaluated positive and negative impacts of boiling on the safety of the raw milk. They determined that the boiling process improves the safety of raw milk, and is responsible for significant in- crease of its microbiological safety. The study also revealed that the safety of raw milk in the Sarajevo Canton derogates from provisions in force for the raw milk. Three different cleaning procedures routinely applied in hygienic sen- sitive working processes were systematically evaluated in the context of their cleaning effectiveness by Jevšnik et al. Based on the results authors conclude that for optimal cleaning outcomes, visual, non- microbiological, and microbiological methods should be combined as an integrated cleaning monitoring strategy. At last but not at least you can enjoy reading this year Roy Emerson winning essay on the theme “International Travel & Health” prepared and submitted by Zarja Zrinski, student from Faculty of Health Sci- ences at University of Ljubljana. The essay was presented at the 2nd IFEH World Academic Congress in Jamaica. With healthy citizens of all ages in mind I wish you will find topics in current issue interesting and informative. Sincerely, Andrej Ovca, Editor-in-Chief Editorial SANITARNO INŽENIRSTVO INŠTITUT ZA SANITARNO INŽENIRSTVO INSTITUTE OF PUBLIC AND ENVIRONMENTAL HEALTH ZBORNICA SANITARNIH INŽENIRJEV SLOVENIJE THE SLOVENIAN ASSOCIATION OF PUBLIC AND ENVIRONMENTAL HEALTH PROFESSIONALS INTERNATIONAL JOURNAL OF SANITARy ENGINEERING RESEARCH © Copyright by Inštitut za sanitarno inženirstvo, 2017. All rights reserved. Reproduction and propagation under the law of copyright is not allowed! International Journal of Sanitary Engineering Research2 Vol. 11  No. 1/2017 Executive editor Aleš KRULEC Institute of Public and Environmental Health, Ljubljana, Slovenia Editor-in-Chief Andrej OVCA, PhD University of Ljubljana, Faculty of Health Sciences, Ljubljana, Slovenia BSc Sanitary engineering Editor Sara TAJNIKAR Institute of Public and Environmental Health, Ljubljana, Slovenia BSc Sanitary engineering Address of the Editorial Board and Administration Institute of Public and Environmental Health Zaloška cesta 155, 1000 Ljubljana, Slovenia Phone: +386 (0)1 546 83 93, Fax: +386 (0)1 546 83 94 E-mail: info@institut-isi.si Website: www.institut-isi.si, https://journal.institut-isi.si Editorial Board Prof. Bryan W. BROOKS, PhD Institute of Biomedical Studies, Center for Reservoir and Aquatic Systems Research, Baylor University, Texas, USA Prof. Branislava KOCIĆ, MD, PhD Public Health Institute of Niš, Serbia Sen. Lect. Graeme MITCHELL, MSc, Liverpool John Moores University, United Kingdom BSc (Hons) Environmental Health Assoc. prof. Susana PAIXÄO, MSc, College of Health Technology of Coimbra, Department of BSc (Hons) Environmental Health Environmental Health, Portugal Prof. Marina ŠANTIĆ, PhD, University of Rijeka, School of Medicine, Rijeka, Croatia BSc Sanitary engineering Prof. Richard M. THACKER, PhD, University of the West of Scotland, United Kingdom BSc Zoology Lect. Helen UDRAS, PhD Tartu Health Care College, Estonia COBIB.SI Union bibliographic catalogue database, dLib.si Digital Library of Slovenia, Index Copernicus, FSTA – Food Science and Technology Abstracts (EBSCO) REVIJA SAnItARno InžEnIRStVo / International Journal of Sanitary Engineering Research - IJSER is indexed and/or abstracted in Published by © Inštitut za sanitarno inženirstvo, 2017 International Journal of sanitary engineering researchVol. 11  No. 1/2017 S it r Engineering Research 3 Contents Indoor environmental quality (IEQ) in Slovenian children daycare centres. Part I: Results of in-situ measurements .............................. 4 Luka PAJEk, Mitja košIR, Živa kRIStl, Katarina KAcJAn žgAJnAR, Mateja DovJAk Indoor environmental quality (IEQ) in Slovenian children daycare centres. Part II: The interrelationship between building characteristics and IEQ ................................................... 19 Luka PAJEk, Mitja košIR, Mateja DovJAk Use of a nudge tool for improving hand hygiene in a nursing team in home for elderly people – case study ................................ 33 Tjaša MlAkAR, Andreja MIhElIč ZAJEc, Mojca JEvšnIk Impact of boiling on raw milk – food safety aspects ....................... 47 Daniel MAEStRo, Arzija PAŠAlIĆ, Fatima JUSUPoVIĆ, Enisa šlJIvo A comparison of three different cleaning methods for reducing contaminants on contact surfaces – a preliminary study ................. 55 Mojca JEvšnIk, Andrej ovCA, Peter RASPoR Is the knowledge of international travel health a legal obligation or a social and personal responsibility? .......................... 67 Zarja ZRInSKI Vol. 11  No. 1/2017 © Inštitut za sanitarno inženirstvo, 2017 International Journal of Sanitary Engineering Research4 Indoor environmental quality (IEQ) in Slovenian children daycare centres. Part I: Results of in-situ measurements 1 Chair of Buildings and Constructional Complexes, Faculty of Civil and Geodetic Engineering, University of Ljubljana, Ljubljana, Slovenia 2 Infrastructure and Real Estate Management Department, European Faculty of Law, Nova Gorica, Slovenia 3 Chair of Health Ecology and Control Division, Faculty of Health Sciences, University of Ljubljana, Ljubljana, Slovenia * Corresponding author Mateja Dovjak, Chair of Buildings and Constructional Complexes, Faculty of Civil and Geodetic Engineering, University of Ljubljana, Ljubljana, Slovenia E-mail: mateja.dovjak@fgg.uni-lj.si Luka PAJEk1, Mitja košIR1, Živa kRIStl2, Katarina KAcJAn žgAJnAR3, Mateja DovJAk1* ABStRACt The number of children enrolled in daycare centres is increasing, while indoor environmental quality of Slovenian children daycare centres remains insufficiently investigated. The purpose of this paper, as Part I of the larger study “Indoor environmental quality (IEQ) in Slovenian children daycare centres”, was to holistically assess indoor environmental quality of 24 playrooms in 17 publicly funded children daycare centres in Slovenia. The performed holistic assessment included simultaneous in-situ measurements of the selected comfort parameters (i.e. indoor air quality, thermal, visual and acoustic comfort), which were compared with legal requirements and recommendations. The results of in-situ measurements showed that the most critical field was the indoor air quality (in 63% of playrooms cCO2i,avg >1667 ppm) and that the indoor environmental quality conditions met all of the legal requirements and recommendations only in 8% of the investigated playrooms. In general, if compared to other EU countries, the conditions in Slovenian facilities were slightly worse. Therefore, a holistic approach to the assessment of indoor environmental quality is vital to achieve a universally comfortable and healthy indoor environment. Part II of this study presents further investigation of interrelationship between different building characteristics and IEQ. key words: indoor environmental quality, in-situ measurements, comfort, public buildings, daycare centres  Original scientific article Received: 27. 10. 2017 Accepted: 20. 12. 2017 International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 5  IntRoDuCtIon The statistical data of EU over the last decade show that the amount of enrolled children in children daycare centres (DCCs) has increased [1], while in Slovenia almost 77% (84750) of children aged one to five were enrolled in DCCs in September 2014 [2]. As the number of children en- rolled in Early Childhood Education and Care (ECEC) is high and seems to be increasing, it is essential that child’s stay in an educational institu- tion is comfortable and without adverse health effects [3–12], especial- ly due to the fact that children are more susceptible to environmental influences, thus being a vulnerable population with particularly higher risk of adverse health effects. Therefore, besides executing field measurements of IEQ parameters in the selected DCCs, one of the goals of our study was also to get a bigger pic- ture in the field of IEQ in DCCs. We were particularly interested in existing studies in the field of IEQ all across the Europe and wider. In order to ana- lyse the state-of-the-art in the field of IEQ in educational building facilities, a comprehensive literature review was carried out. Table 1 represents study summary of 24 selected research papers dealing with indoor envi- ronment quality in buildings intended for education (e.g. DCCs, schools). Among the referenced studies (Table 1), the most investigated indoor comfort field is IAQ, while the least investigated is visual comfort. Ther- mal comfort [12–15], indoor air quality (IAQ) [4, 7, 10, 16–23, 30–32], visual comfort [5, 6, 8] or acoustic comfort [3, 25–27] and/or their im- pact on human health is relatively well investigated either in DCCs or in schools. In many cases studies identified the conditions as inadequate and hazardous for children. Cano et al., Teli et al. [11] and De Giuli et al. [29] presented a wider aspect as they investigated two IEQ fields, for example, by taking into account thermal comfort and indoor air qual- ity at the same time. Very few studies of IEQ were made in Slovenian DCCs, mostly focusing only on acoustic comfort, for example a study made by Kacjan Žgajnar et al. [25]. In addition, the literature review showed that there is no such study, which would simultaneously con- sider all of the four comfort fields (i.e. thermal, visual, acoustic comfort and IAQ). table 1: An overview of the selected reviewed research papers Comfort field Author (year) location Study area Study population Study parameters thermal comfort Fabbri (2013) [13] Italy, Reggio Emilia, N = 1 DCC Thermal comfort (PMV, PPD) Playrooms with 4–5 year old children Tai, RHai, vai, Tmr, PMV, PPD Hwang et al. (2009) [14] Taiwan, N = 14 schools Thermal comfort (TSV) Children 12–17 years old TSV Mors et al. (2011) [15] Netherlands, Eindhoven, N = 3 schools Thermal comfort (PMV, TSV) Classrooms with 9–11 years old children Tai, RHai, vai, Tmr, PMV, TSV yun et al. (2014) [12] S. Korea, Seoul, N = 10 DCCs Thermal comfort (PMV) Naturally ventilated playrooms with children 4–6 years old Tai, RHai, vai, Tmr, PMV L. Pajek, M. Košir, Ž. Kristl et al.Indoor environmental quality (IEQ) in Slovenian children daycare centres. Part I: Results of in-situ... Children are more susceptible to environmental influences, thus being a vulnerable population with particularly higher risk of adverse health effects. © Inštitut za sanitarno inženirstvo, 20176  Comfort field Author (year) location Study area Study population Study parameters Indoor air quality Araújo-Martins et al. (2014) [16] Portugal, Lisbon and Porto, N = 45 DCCs IAQ and health Playrooms with 3 months to 6 year old children cCO2i, biological and chemical hazards, Tai, RHai Cars et al. (1992) [17] Sweden, Teleborg (Växjö), N = 7 DCCs Infectious diseases and IAQ Playrooms in DCCs and in renovated dwellings cCO2i, absence due to an infectious disease Daneault et al. (1992) [18] Canada, Montreal, N = 91 DCCs IAQ Randomly selected playrooms cCO2i, Tai, RHai Gładyszewska- Fiedoruk (2013) [19] Poland, Białystok, N = 3 DCCs Correlation between IAQ and RH Playrooms with 3–6 year old children cCO2i, Tai, RHai Roda et al. (2011) [20] France, Paris, N = 28 DCCs IAQ Playrooms with toddlers cCO2i, biological and chemical hazards, Tai, RHai Ruotsalainen and Jaakkola (1993) [21] Finland, Espoo, N = 30 DCCs IAQ Old and new playrooms cCO2i, ventilation rate, chemical hazards, odours, Tai, RHai, St-Jean et al. (2012) [10] Canada, Montreal, N = 21 DCCs IAQ Playrooms with a capacity of at least 40 children cCO2i, chemical hazards, Tai, RHai Stankeviča and Lešinskis (2012) [22] Latvia, Riga, N = 6 DCCs IAQ Playrooms in old, new and renovated DCCs cCO2i, Tai, RHai Zuraimi et al. (2008) [23] Singapore, N = 104 DCCs IAQ of DCCs in tropical climate Randomly selected playrooms cCO2i, cCOi, Tai, RHai, vai, biological hazards visual comfort Hathaway et al. (1992) [5] Canada, schools Impact of artificial and natural light on children Children in classrooms with artificial or natural daylight Performance and health analysis of children Heschong Mahone Group (1999) [6] USA, California, N = 3 schools Impact of daylight on children Children in well and under-lit classrooms Performance analysis of children Nicklas and Bailey (1997) [8] USA, N. Carolina, N = 5 schools Impact of daylight on children Children in well and under-lit classrooms Performance analysis of children Acoustic comfort Chatzakis et al. (2014) [3] Greece, Crete, Heraklion, N = 10 DCCs Noise level 18 playrooms Leqi, impact of noise on health Kacjan Žgajnar et al. (2009) [24] Slovenia, Ljubljana, N = 3 DCCs Noise level in the workplace Educators in playrooms intended for children between 3 and 6 years old Leqi, impact of noise on health of educators Kacjan Žgajnar et al. (2009) [25] Slovenia, Ljubljana, N = 3 DCCs Noise level in playrooms Playrooms intended for children between 3 and 6 years old Leqi, impact of noise on health McAllister et al. (2009) [26] Sweden, Linköping, N = 3 DCCs Noise level in playrooms 10 children without reported hearing problems Leqi, impact of noise on health Sjödin et al. (2012) [27] Sweden, Umea°, N = 17 DCCs Noise level in the workplace Educators impact of noise on health Multiple comfort analysis Cano et al. (2012) [28] Portugal, Lisbon, N = 19 DCCs IAQ and thermal comfort 125 playrooms intended for children old between 3 months and 6 years Tai, RHai, vai, Tmr, cCO2i, cCOi, biological and chemical hazards De Giuli et al. (2014) [29] Italy, Padua, N = 3 schools IAQ, thermal comfort and visual comfort 8 classrooms in primary schools Tai, RHai, vai, To, PMv, PPD, cCO2i, Ei Teli et al. (2012) [11] England, Hampshire, N = 1 school IAQ and thermal comfort Classrooms with children between 7 and 11 years old Tai, RHai, vai, Tmr, PMV, PPD, TSV, cCO2i Tai – indoor air temperature; RHai – indoor air relative humidity; vai – indoor air velocity; Tmr – mean radiant temperature; To – operative temperature; PMV – predicted mean vote index; PPD – predicted percentage of dissatisfied; TSV – thermal sensation vote; cCO2i – indoor concentration of carbon dioxide; cCOi – indoor concentration of carbon oxide; Leqi – indoor equivalent noise level; Ei – daylight illuminance of work plane L. Pajek, M. Košir, Ž. Kristl et al. Indoor environmental quality (IEQ) in Slovenian children daycare centres. Part I: Results of in-situ... International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 7  Therefore, it can be concluded that these four areas of comfort in DCCs are not treated equally, as some are represented in the research less of- ten than others. In this respect, in recent years the importance of high quality ECEC is reflected in a high volume of joint reflection on policies and programmes between the European Commission and the Member States [33]. As can be seen, the IEQ of children daycare centres as well as other educational institutions was relatively well investigated through- out the facilities across the EU and wider, which was found out through the review of the published papers. Surprisingly, the quality of indoor en- vironment in Slovenian DCCs has not been sufficiently investigated. Con- sequently, the objective of our study was to examine the situation in Slov- enian DCCs from the IEQ perspective. Therefore, measurements of selected parameters of visual, thermal and acoustic comfort, as well as indoor air quality were carried out. Several playrooms were sampled from the selected DCCs in Slovenia in order to execute in-situ measurements of the selected comfort parameters. Hence, the above mentioned factors affecting human comfort in buildings were investigated in 24 playrooms in 17 DCCs. The study took place from March to June 2013. The indoor environment was investigated in order to improve IEQ conditions in DCCs. The latter was done by examining minimal criteria according to national and EU legal requirements, applicable recommendations or standards. MEtHoDS Area and time of observation The research was carried out in 17 randomly selected children daycare centres (anonymised and denominated by letters A–R) located in Slove- nia, which included 24 playrooms intended for children aged 3 to 5. The research took place at targeted DCCs from March to June 2013. The conducted research protocol is presented in Figure 1. Figure 1: Research protocol L. Pajek, M. Košir, Ž. Kristl et al.Indoor environmental quality (IEQ) in Slovenian children daycare centres. Part I: Results of in-situ... © Inštitut za sanitarno inženirstvo, 20178  Measurements The required data were collected in-situ in the selected DCCs by re- searchers conducting measurements of the studied parameters. Meas- urements took place in forenoon, particularly between 9 and 12 am (i.e. after breakfast and before lunch) in occupied playrooms. Holistic evaluation of IEQ included the following measurements. Indoor air tem- perature (Tai), indoor air relative humidity (RHai), indoor air velocity (vai) and surface temperature (Tsurf) were measured to evaluate thermal com- fort of the investigated playrooms. Field technicians measured daylight illuminance of work plane (Ei) and window glass light transmittance (LT) as the selected visual comfort parameters. To evaluate the IAQ, indoor concentration of carbon dioxide (cCO2i) was measured. Indoor equiva- lent noise level (Leqi) was the selected and measured parameter of acoustic comfort. In addition, two selected outdoor parameters were measured: outdoor noise level (Leqe) and outdoor concentration of car- bon dioxide (cCO2e). For the purpose of the study the following meas- urement equipment was used: Testo 445 (Tai, RHai, vai), Testo 535 (cCO2i, cCO2e), Raytek Raynger MX (Tsurf) and Voltcraft DT 8820 (Leqi, Leqe, Ei). Outdoor air temperature (Tae), relative humidity of outdoor air (RHae) and air velocity (vae) were provided by Slovenian Environment Agency [34]. All the selected indoor parameters were recorded every 20 minutes, with the exception of carbon dioxide concentration, which was recorded every 5 minutes. Measuring instruments were placed out of children’s reach. A typical selection and position of measuring points is presented on a floor plan of playroom A1 (Figure 2). Figure 2: Measurement points in playroom A1 L. Pajek, M. Košir, Ž. Kristl et al. Indoor environmental quality (IEQ) in Slovenian children daycare centres. Part I: Results of in-situ... International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 9  All of the measurements were taken at a height of 0.70 m above the floor, with the exception of surface temperature measurements, which were taken on all the circumferential surfaces. Although the work plane for horizontal illuminance measurements in DCCs should be positioned lower than at 0.70 m above the floor, this distance was nevertheless used in order to prevent inquisitive children interfering with the measure- ments. However, presuming that the illuminance at lower work planes is higher than at 0.70 m, the measurements are on the safe side. Measure- ments of daylight illuminance were performed for the actual state of play- rooms – positions of furniture and shading systems were preserved. All the sources of artificial light were turned off. Indoor environment condi- tions were evaluated and compared to legal requirements and recom- mendations for DCCs, defined in the following documents: • Slovenian national legislation: O.J. RS, No. 42/02, 105/02 [35]; O.J. RS, No. 73/00, 75/05, 33/08, 126/08, 47/10, 47/13 [36]; O.J.RS, No.17/06, 18/06 – ed., 43/11 – ZVZD-1[37]; • Slovenian national guidelines: TSG-1-005:2012 [38]; • International standards and recommendations: ANSI/ASHRAE Standard 62.1-2007 [39]; CEN CR 1752:2001[40]; EN 12464- 1:2011[41]; EN 15251:2010[42]; ISO 7730:2005 [43]. Preparation of data All the required data were collected and prepared for further investiga- tion. The dimensions (i.e. floor space, height, window openings) and orientation of the DCC playrooms were recorded by the field techni- cians. DCC managers provided information regarding lists of children present in the analysed playrooms and the age of buildings. For the pur- pose of evaluating indoor environmental quality, additional calculations of playroom floor area per occupant, playroom volume, mean radiant temperature (Tmr), predicted mean vote index (PMV), predicted percent- age of dissatisfied (PPD), window to floor ratio (WFR), illuminance uni- formity (i.e. Ei,min/ Ei,avg and Ei,avg/ Ei,max) and percentage of dissatisfied with the air quality (PPDIAQ) were made. Thermal comfort parameters were calculated according to ISO 7730:2005. The calculation of PPDIAQ parameters was performed with the use of Equation 1 based on CEN CR 1752:2001. PPDIAQ = 395 (–15.15(cCO2i,avg – cCO2e) –0.25) (1) RESultS Sample building characteristics For the purpose of further analysis, in initial step sample building charac- teristics were investigated, as one of the potential factors that could affect IEQ. All of the investigated DCCs were publicly funded; none of them was privately run. In 2013 the average age of the selected buildings was 43 years, with the average year of construction 1970. The oldest building in the entire sample was constructed in 1899, as a residential villa; the L. Pajek, M. Košir, Ž. Kristl et al.Indoor environmental quality (IEQ) in Slovenian children daycare centres. Part I: Results of in-situ... © Inštitut za sanitarno inženirstvo, 201710  newest was constructed in 2013 as a low-energy children daycare cen- tre. Eight out of seventeen buildings were recently renovated with the aim to lower their energy demand. All of the DCCs were renovated only by re- placing windows. Playrooms in every DCC were naturally ventilated, with the exception of DCCs P and R, which were ventilated mechanically. The latter DCCs were also classified as low-energy buildings and were at the same time the youngest buildings (Table 2) included in the study. The average floor area of the selected playrooms was 41.3 m2 and the aver- age volume 132.2 m3. The average floor area per occupant was 2.2 m2. Only minority of playrooms (17%) had the average floor space equal to or higher than what is required by the Slovenian legislation (i.e., at least 3 m2/child) [36]. None of the investigated playrooms had north orientation, with most of them (i.e. 9) oriented south. Basic information and building characteristics of each selected DCC facility are presented in Table 2. table 2: Basic information and building characteristics of the selected DCCs Daycare centre Year of construction Recent renovationb Playroom no. Playroom occupation (children + staff) Floor area [m2] Floor area per occupant [m2/occ] volume [m3] Area of windows [m2] orientation of majority of windows, azimuth [°] A 1952 yes A1 14 + 2 35.7 2.2 102.2 7.3 W, 290 A2 20 + 2 35.8 1.6 112.2 10.3 W, 290 B 1979 yes B1 19 + 2 52.7 2.5 155.5 16.8 W, 292 C 1899 yes C1 14 + 2 35.2 2.2 131.5 11.5 E, 100 D 1963 No D1 18 + 2 44.6 2.2 161.1 20.8 NW, 310 D2 16 + 3 37.2 2.0 116.8 15.5 S, 178 D3 16 + 1 46.9 2.8 142.6 13.8 SE, 130 E 1906 No E1 14 + 2 36.3 2.3 127.4 3.3 W, 275 F 1979 No F1 19 + 3 39.0 1.8 116.5 14.8 E, 100 G 1979 yes G1 14 + 2 41.9 2.6 151.7 10.0 S, 160 G2 14 + 2 36.0 2.3 164.2 13.1 SE, 150 H 1976 yes H1 16 + 2 44.6 2.5 133.8 16.7 SW, 210 I 1973 yes I1 18 + 2 43.7 2.2 128.6 15.0 SE, 142 J 1982 No J1 20 + 2 33.8 1.5 113.3 11.5 SE, 128 J2 15 + 2 32.9 1.9 111.0 11.8 S, 149 K 1976 yes K1 18 + 2 38.2 1.9 99.4 10.7 E, 80 K2 21 + 2 46.8 2.0 145.9 13.4 SE, 128 L 1976 No L1 20 + 2 41.0 1.9 132.8 18.4 S, 172 M 1979 No M1 14 + 3 42.4 2.5 122.1 9.9 SW, 220 N 1971 No N1 17 + 2 50.3 2.6 174.5 21.5 S, 180 O 1972 yes O1 13 + 2 44.7 3.0 134.1 11.6 S, 200 O2 17 + 2 49.1 2.6 146.3 13.2 S, 158 Pa 2013 No P1 21 + 2 39.2 1.7 118.0 17.3 S, 178 Ra 2012 No R1 17 + 2 43.6 2.3 132.2 15.4 S, 164 a Low-energy DCCs; b Energy retrofit: replacement of windows Measurement and calculation of the selected IEQ parameters The highest measured outdoor air temperature during the measurement time interval (9–12 am) was 32.4 °C, and the lowest –1.4 °C [34]. In the same way, the average value of measured outdoor CO2 concentra- tion was 387 ppm (330–445 ppm), the average outdoor equivalent noise level 50 dB (30–75 dB). Table 3 represents general characteristic values of measurements and calculations of the selected IEQ parame- ters in all the playrooms among the analysed DCCs. The measured val- L. Pajek, M. Košir, Ž. Kristl et al. Indoor environmental quality (IEQ) in Slovenian children daycare centres. Part I: Results of in-situ... International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 11  ues of thermal and visual comfort parameters were largely dispersed. Thus, in Table 3 the median values were used instead of arithmetic mean, to represent general conditions in playrooms. The main results of IEQ measurements compared with legal requirements and recommen- dations are presented in the subsections below. table 3: Measured and calculated values of indoor environmental quality parameters among all the 17 DCCs (24 playrooms) Parameters Symbol Description unit Min Max Median Tai indoor air temperature °C 19.3 27.4 23.7 tsurf surface temperature °C 13.5 34.2 22.3 RHai indoor air relative humidity % 29.1 68.5 47.2 vai indoor air velocity m/s 0.00 0.50 0.04 PMv predicted mean vote - –0.33 1.10 0.19 PPD predicted percentage of dissatisfied % 5 29 6 lt light transmittance of windows - 0.52 0.89 0.69 WFR window to floor ratio % 9.1 45.0 30.0 Ei average indoor daylight illuminance lx 44 2655 352 - uniformity of illuminationa - 0.01 0.38 0.17 cCo2i indoor CO2 concentration ppm 389 3613 1400 PPDIAQ predicted percentage of dissatisfied with IAQ % 9 43 27 leqi indoor equivalent noise level dB 30 95 70 a Ratio between minimal and average illuminance. Thermal comfort During the conducted measurements indoor air temperature did not meet the required values (i.e., 19–24 °C) according to Slovenian legal requirements [35] in 37% of playrooms. In those playrooms the air temperature was too high, with the highest values reached in playroom R1 (25.5–27.4 °C). However, in relation to the recommendations [42]) (i.e., 17.5–22.5 °C), the recommended indoor air temperature was en- sured only in 8% of the playrooms, with too high air temperatures in the majority of the playrooms. Radiant temperature asymmetry was not detected in any of the analysed playrooms. Nevertheless, the lowest surface temperature of 13.5 °C was measured on the external wall sur- face in playroom G1, as a consequence of present thermal bridge. In- door air relative humidity was within the acceptable limits of 40 to 60% [36, 42] in 54% of the playrooms, while in other playrooms the air was mostly too dry (i.e. RHai < 40%). The measured indoor air velocity ex- ceeded the permitted value (i.e., vai < 0.19 m/s) [35] in 17% of the playrooms and the recommended value (i.e., < 0.15 m/s) in 29% of the playrooms. However, according to the recommendations [35, 42], appropriate PMV and PPD (i.e.,± 0.7 PMV, PPD < 15%) values were still achieved in 83% of the playrooms. Indoor air quality (IAQ) In 63% of the playrooms the measured concentrations of CO2 exceeded the value permitted by Slovenian legislation (i.e., < 1667 ppm) [35]. Overall, nearly 80% of the playrooms had mean CO2 concentrations ex- ceeding 1000 ppm, which is recommended as the highest value in the L. Pajek, M. Košir, Ž. Kristl et al.Indoor environmental quality (IEQ) in Slovenian children daycare centres. Part I: Results of in-situ... During the conducted measurements indoor air temperature did not meet the required values according to Slovenian legal requirements in 37% of playrooms. In 63% of the playrooms the measured concentrations of CO2 exceeded the value permitted by Slovenian legislation. © Inštitut za sanitarno inženirstvo, 201712  ANSI/ASHRAE Standard 62.1-2007 [39]. The highest achieved mean CO2 concentration measured in playroom B1 was 2584 ppm, while the highest measured value of 3613 ppm was reported in playroom R1. According to standard EN 15251:2010 [42] and Equation 1, 8% of the investigated playrooms were classified as indoor air quality class I (PP- DIAQ < 15%), 17% of playrooms were classified as class II (PPDIAQ < 20%), 33% as class III (PPDIAQ < 30%) and the rest as class IV (PPDI- AQ > 30%). In more than half of the playrooms, the PPDIAQ value was higher than 25%. Visual comfort One playroom (E1) did not meet the requirement of Slovenian legislation for the WFR in DCCs (i.e., > 20% of the floor plan) [36, 42]. Playroom L1 had the highest percentage of lighting openings in relation to the floor area (45%) due to its supplementary clerestory windows. The maximum ratio between the height and the depth of the playrooms is limited by Slovenian legislation to 2.5 [36, 42]. In contradiction to the legal requirements, in 18% of playrooms the room depth was more than 2.5 times greater than the room height. According to standard [42], in 54% of the playrooms the recommended average work plane illuminance of at least 300 lx was ensured by daylighting during the time of conducted measurements. Acoustic comfort In general, high noise levels in the selected playrooms were a conse- quence of children activity in the playrooms. In most cases the internal- ly generated noise was dominant over the external ambient noise sourc- es. According to Slovenian legislation [38], indoor noise level was in general too high during the measurements. Only 58% of the playrooms met the Slovenian legal requirements for noise exposure at work (i.e., < 70 dB) [37]. However, it has to be noted that noise level measurements were performed only for the period of three hours, while the legal re- quirements consider the noise exposure during the entire time span of operating hours. The highest and the lowest mean indoor noise levels were 83 dB (playroom A2) and 51 dB (playroom F1). Although indoor equivalent noise level was adequate in the majority (67%) of playrooms, it has to be noted that also the impulse noise should be taken into con- sideration. Maximum noise levels in some playrooms exceeded 90 dB due to high children activity (e.g. playing, singing). Holistic assessment In order to holistically assess the IEQ in the analysed DCCs, all of the four aspects of comfort must be simultaneously evaluated. For each as- pect one parameter was selected for a holistic assessment. Thus, PMV was selected to evaluate thermal comfort; average work plane illumi- nance with daylight was selected to evaluate visual comfort, indoor CO2 concentration for IAQ and equivalent noise level for acoustic comfort. Table 4 represents the selected parameters of observation and general measurement results in all the 24 investigated playrooms. L. Pajek, M. Košir, Ž. Kristl et al. Indoor environmental quality (IEQ) in Slovenian children daycare centres. Part I: Results of in-situ... Maximum noise levels in some playrooms exceeded 90 dB due to high children activity (e.g. playing, singing). International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 13  table 4: Measurement results of the selected basic parameters in each playroom thermal comfort visual Comfort IAQ Acoustic comfort Playroom no. PMv [-] Ei,avg [lx] cCo2i,avg [ppm] leq,i,avg [dB] A1 0.01 139 1643 64 A2 –0.05 449 1805 83 B1 –0.30 492 2584 71 C1 0.09 136 1400 70 D1 0.33 697 1389 67 D2 0.25 918 2094 80 D3 0.69 356 1176 61 E1 0.09 74 1000 67 F1 0.43 1285 1449 51 G1 0.03 126 1433 65 G2 0.29 183 1657 60 H1 –0.33 347 1812 74 I1 0.13 690 2020 75 J1 0.66 682 1910 69 J2 0.31 162 761 65 K1 0.72 294 905 75 K2 0.31 97 628 71 L1 0.12 521 1012 64 M1 –0.02 121 1967 74 N1 –0.02 463 867 69 O1 0.42 44 1125 70 O2 0.13 163 1192 75 P1 0.75 915 1181 76 R1 1.10 2655 2023 67 Furthermore, the measured values were compared to the recommended ones. Such comparison is presented in Figure 3. The measured values of thermal and visual comfort parameters were largely dispersed. Thus, in Figure 3 the median values were used for all of the comfort types. Figure 3: Comparison of the selected IEQ fields and their parameters for playrooms A1–R1, considering parameters of thermal, visual, acoustic comfort and indoor air quality. Solid line represents the recommended value and dotted line represents the median value of the playrooms. The PMV values are shown as absolute numbers. L. Pajek, M. Košir, Ž. Kristl et al.Indoor environmental quality (IEQ) in Slovenian children daycare centres. Part I: Results of in-situ... © Inštitut za sanitarno inženirstvo, 201714  If the results are holistically observed, in playrooms A1 and A2 (8% of playrooms) all of the IEQ fields were within the recommended values. In 10 playrooms (42%), only one IEQ field did not meet the recommended values. In the rest of playrooms (50%), two or three uncomfortable IEQ parameters were identified simultaneously. None of the investigated play- rooms had all the selected IEQ parameters inappropriate. DISCuSSIon Poor thermal conditions of indoor environment can have negative im- pact on comfort and learning skills or may even cause adverse health effects, since children are more sensitive to high air temperatures than adults [12]. The measured air temperatures in the playrooms, which were considered within this paper, were similar to those in the studies conducted in Canada [18], Portugal [16] and Latvia [22], but higher than those in Portugal [44] and lower than those measured in South Korean [12] or Singaporean [23] facilities. Inadequate control over air humidity of living environment can result in suitable conditions for the growth of mould, which has adverse effects on occupants’ health [45–47]. The RH values, which were measured in DCCs during the presented study, were found to be less appropriate (i.e. lower) than those measured in Canada [18], Portugal [28], Italy [13], France [20] or South Korea [12]. At the same time, they were more suitable than in Singapore DCCs [23]. However, the latter is cli- mate consequence of Singapore’s high humidity climate. The measured mean air velocity in the selected DDCs was similar to the values identified by Mors et al. [15] in Netherlands and yun et al. [12] in South Korea. On the other hand, they were lower than those meas- ured in Singapore by Zuraimi and Tham [23]. In contrast to previously conducted studies [16, 22, 28], where occupants were satisfied with thermal comfort or the reasons for discomfort were too cold thermal conditions, the PPD values identified by measurements of this study were more affected by too warm indoor environment. The identified CO2 concentrations (an indicator of ventilation rates) in the investigated Slovenian DCCs were similar to those measured in Portugal [16], Canada [10, 18], Latvia [22] and Poland [19], where in most cases the measured CO2 concentrations exceeded 1000 or 2000 ppm. How- ever, in comparison to studies conducted in Scandinavian countries [17, 21, 31], France [20] and in Singapore [23], where the average CO2 con- centrations rarely exceeded 1000 ppm, the measured CO2 concentra- tions in Slovenian DCCs were higher and, thus, less appropriate. The results of the conducted measurements of horizontal daylight illumi- nance (Figure 3) show that in 37% of the analysed playrooms the aver- age illuminance values were below the recommended value of 300 lx de- fined in EN 12464. However, it has to be emphasized that only daylighting was investigated (i.e. measured), although the recommenda- tions of the EN 12464 standard relate to lighting in general (i.e. daylight- ing and artificial lighting). Among the studied playrooms in Slovenian DCCs, the most common reasons for poor daylighting were the window L. Pajek, M. Košir, Ž. Kristl et al. Indoor environmental quality (IEQ) in Slovenian children daycare centres. Part I: Results of in-situ... The results of the conducted measurements of horizontal daylight illuminance show that in 37% of the analysed playrooms the average illuminance values were below the recommended value of 300 lx defined in EN 12464. International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 15  properties (i.e. area, shape, type of glazing, etc.). In addition, the penetra- tion of daylight was often obstructed by various items attached to the glazing (e.g. shaped paper, drawings). One of the reasons for visual dis- comfort was also the inappropriate use of shading devices. In other words, in some playrooms shades were in shading position when shading was not needed (e.g. overcast sky, shading of western windows in fore- noon). In several playrooms the shading system was even damaged and therefore inoperable for the users. This is a common problem in public buildings, as identified also by De Giuli et al. [29] in their study. Excessive noise levels in DCCs represent health risk and discomfort for children and staff, which has been considered by numerous studies [25–27]. The measured noise levels in the investigated playrooms were comparable to the findings of some other studies [25, 26] and were relatively high. The problem of excessive noise levels in Slovenian DCCs might be additionally amplified by inappropriate reverberation times, which were highlighted by the findings of Kacjan Žgajnar et al. [48]. ConCluSIonS Holistic approach to the assessment of indoor environmental quality with all the IEQ fields taken into consideration is vital to achieve a universally comfortable and healthy indoor environment. All the parameters of IEQ are by some means directly or indirectly interconnected. Thus, they can- not be assessed separately one at a time. Although some authors (see references [29, 49]) do not advise ranking of buildings with a combined assessment index, a holistic approach is still necessary, where as many comfort parameters as possible should be investigated simultaneously, but not necessarily combined into a single rating. Therefore, a multi-disci- pline approach and cooperation of experts from different professional fields is encouraged. There are very few studies that would comprehen- sively and simultaneously investigate thermal comfort, indoor air quality, visual and acoustic comfort. Within the presented paper such approach was used to assess playrooms in the selected DCCs. The IEQ conditions in some of the investigated playrooms did not meet the recommended criteria. However, it must be noted that there was no playroom where all of the four considered comfort types would be inadequate. Moreover, it has to be stressed that the measurement results showed that in 42% of the investigated playrooms only one comfort field deviated from the mini- mal required and the recommended values (Figure 3). The one uncom- fortable condition could stay unidentified if not all the comfort fields were analysed. Contrasting other studies, which deal predominantly with IEQ, the presented results show the importance of holistic approach. An in-depth analysis of the collected data showed that among the 24 studied playrooms the most critical field of indoor environmental quality was IAQ with 75% of playrooms above the recommended value (1000 ppm). The percentage of playrooms that exceeded the recommendations in the fields of visual and acoustic comfort was also relatively high, with 46% and 38%, respectively. Comparatively, thermal comfort recommen- dations were exceeded only in 8% of considered playrooms, thus defining L. Pajek, M. Košir, Ž. Kristl et al.Indoor environmental quality (IEQ) in Slovenian children daycare centres. Part I: Results of in-situ... The problem of excessive noise levels in Slovenian DCCs might be additionally amplified by inappropriate reverberation times, which were highlighted by the findings of Kacjan Žgajnar et al. [48]. Contrasting other studies, which deal predominantly with IEQ, the presented results show the importance of holistic approach. © Inštitut za sanitarno inženirstvo, 201716  thermal comfort as the most controlled. According to previously conduct- ed studies (see references [11, 12, 15]), the IEQ recommendations and legal requirements for buildings intended for children should be reconsid- ered, since children response to the indoor environment differently than adults. In addition, the results of this paper indicate that the legislation regarding IEQ in Slovenian DCCs might be insufficient, since the identi- fied IEQ was better in some other EU countries with generally stricter le- gal requirements for indoor environment, e.g. Denmark, France and Swe- den [50]. This study or similar ones (see reference [30]) can be used to provide a useful evidence base for the formulation and targeting of poli- cies for improving IEQ in school or daycare buildings. Part II of this study further examines the interrelationship between various building character- istics, occupants’ behaviour and several parameters of IEQ. Acknowledgements This study was conducted in collaboration with the selected children daycare centres in Slovenia. The children daycare centres included in the research were randomly selected and were given free choice to par- ticipate or not in the research. The authors gratefully acknowledge the cooperation of the managers and educators of the participating day care centres, field technicians and other project collaborators. REFEREnCES [1] Eurostat. Eurostat. Education statistics 2014ec.europa.eu/eurostat/ statistics-explained/index.php/Main_Page#Pre-primary_education (2014, accessed 27 June 2016). [2] STAT SI. Statistical office Republic of Slovenia. Preschool education in kindergartens, Slovenia, school year 2013/14 – final datahttp://www. stat.si/ (2014, accessed 27 June 2014). 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Part I: Results of in-situ... © Inštitut za sanitarno inženirstvo, 2017 International Journal of sanitary engineering researchVol. 11  No. 1/2017 S it r Engineering Research 19 Indoor environmental quality (IEQ) in Slovenian children daycare centres. Part II: the interrelationship between building characteristics and IEQ Luka PAJEk1, Mitja košIR1, Mateja DovJAk1* ABStRACt In the process of building design it is important to consider the interconnected impact of occupants’ behaviour and building characteristics on the quality of indoor environment. Moreover, it is necessary to identify how potential energy renovation measures may influence the indoor environmental quality. For this reason, this paper, as Part II of the larger study “Indoor environmental quality (IEQ) in Slovenian children daycare centres”, further investigates the results of in-situ measurements, presented in Part I. Additionally, comparative study of the potential impacts of building renovations on IEQ was performed. The IEQ was identified as poorer in renovated (i.e. where windows were replaced) and newly constructed low-energy buildings. Furthermore, the most significant connection was identified between indoor air quality and outdoor temperature, which is most likely the consequence of occupant’s behaviour (opening of windows). The results of the study should raise the awareness regarding possible adverse health effects of indoor environment on occupants’ health, as well as to serve as recommendations for building designers. key words: indoor environmental quality, holistic approach, comfort, public buildings, daycare centres 1 Chair of Buildings and Constructional Complexes, Faculty of Civil and Geodetic Engineering, University of Ljubljana, Ljubljana, Slovenia * Corresponding author Mateja Dovjak, Chair of Buildings and Constructional Complexes, Faculty of Civil and Geodetic Engineering, University of Ljubljana, Ljubljana, Slovenia E-mail: mateja.dovjak@fgg.uni-lj.si Received: 27. 10. 2017 Accepted: 22. 12. 2017 Original scientific article  © Inštitut za sanitarno inženirstvo, 201720  IntRoDuCtIon This is the second part of the larger study “Indoor environmental quality (IEQ) in Slovenian children daycare centres”. The first part (Part I: Re- sults of in-situ measurements) of this study presented the data, ac- quired by in-situ measurements of the selected comfort parameters in randomly selected 17 Slovenian children daycare centres (DCCs). The study compared the collected measured data and thus the conditions in DCC facilities with the policy requirements and recommendations. Fur- thermore, the IEQ conditions of Slovenian DCCs were compared to the conditions of DCC facilities in other countries, where similar studies had been made. However, the presented paper further extends the analysis of the results to the study of interrelationships between IEQ parameters, environmental conditions and building characteristics of the analysed DCCs. In other words, it was of further interest if building (e.g. age of buildings) or environmental (e.g. outdoor air temperature) characteris- tics influence any of the considered IEQ parameters. The authors kindly suggest the readers to firstly consider the first part of this study (i.e. In- door environmental quality (IEQ) in Slovenian children daycare centres. Part I: Results of in-situ measurements) in order to better understand the background of the research presented in this paper. According to statistical data [1, 2], the number of children enrolled in Early Childhood Education and Care (ECEC) is growing every year. Be- cause the number of children registered in ECEC is increasing, even greater attention must be paid to comfortable conditions in indoor envi- ronment of DCCs. The latter must be provided at all times, including the elimination of adverse health effects [3–9]. Increasing number of children enrolled in DCCs results in the shortage of building stock de- signed specifically for educational purpose. In Europe, only Denmark, Finland, Sweden and Norway do not report any significant imbalances between the demand and supply for the entire ECEC age range [10]. The problem of overcrowded DCCs is usually solved by altering the ex- isting norms for class sizes, or with repurposing of alternative facilities (e.g. remodelling of residential buildings). In Slovenia the government authorities amended the main ECEC legislation in 2010 to allow build- ings originally constructed for purposes other than ECEC (e.g. residen- tial, administrative or office buildings) to be used as ECEC settings. Dur- ing the same year, 118 buildings of this type were brought into use. Several buildings were repurposed and renovated due to their age and increasingly stringent energy saving demands (e.g. modifications of building envelope or Heating, Ventilation and Air Conditioning – HVAC systems, replacement of windows, etc.). Although the executed renova- tions are ideal opportunities to improve energy performance and at the same time also indoor comfort, this is mostly not the case, as in gener- al only the energy efficiency aspects of the building renovation are ad- dressed [11]. Even more, the aspects of healthy and comfortable living environment are often disregarded, as they represent a “collateral” dam- age on the path to higher energy efficiency [12]. Thus, some fundamen- tal decisions in building construction design, for example the choice of glazing characteristics, are essential for later behaviour of a building, L. Pajek, M. Košir, M. Dovjak Indoor environmental quality (IEQ) in Slovenian children daycare centres. Part II: The interrelationship... The presented paper further extends the analysis of the results to the study of interrelationships between IEQ parameters, environmental conditions and building characteristics of the analysed DCCs. Although the executed renovations are ideal opportunities to improve energy performance and at the same time also indoor comfort. International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 21  which affects indoor environmental quality [11, 13, 14].The above de- scribed situation can in the end unintentionally result in poor indoor en- vironmental conditions and may cause sick building syndrome and/or building related illnesses [15, 16]. Wargocki and Wyon [17] warned that impulsive and oblivious attempts to reduce energy use in buildings could lower a child’s learning abilities by 30%. In the last three dec- ades, an increasing number of studies have reported uncomfortable and unhealthy conditions in educational institutions. All the indoor environ- mental quality (IEQ) fields were more or less investigated with a similar proportion, with most studied definitely being indoor air quality (IAQ). Although IEQ has become a growing concern over time, very few holis- tic studies have been carried out in DCCs, as most of them considered each field of living or working environmental quality separately, i.e. noise, thermal comfort and indoor air quality, one or two at a time. Nevertheless, De Giuli et al. [18] investigated several indoor environ- mental quality fields in Italian schools simultaneously. The focus was on measuring indoor environment conditions, which included thermal com- fort, IAQ and illuminance measurements. Throughout the process of ensuring and providing comfortable and healthy indoor environment for children, a holistic and multidisciplinary approach is essential. Consequently, the objective of our study was to holistically assess all of the IEQ fields. This was executed on the basis of in-situ measurement results, presented in the first part of this article Indoor environmental quality (IEQ) in Slovenian children daycare cen- tres. Part I: Results of in-situ measurements. The measurement data consisted of parameters of visual, thermal and acoustic comfort, as well as indoor air quality. For a holistic and multidisciplinary study on indoor environmental issues, the objective of our research was to determine the environmental or building related characteristics that influence IEQ on a sample of 24 playrooms in 17 DCCs in Slovenia. The study took place from March to June 2013. The main goal was to get better under- standing of the indoor environment conditions in DCCs, which are pub- lic facilities and where a lot of building renovations, primarily focused on energy performance, have been or will be conducted in the near fu- ture. The stated is of great importance, since DCCs represent an envi- ronment that may have a decisive influence on children’s physical and mental development. In the first place, the acquired knowledge would enable designers to have better control over potentially negative effects in future building renovations. Finally, the results of the study should serve as a basis for recommendations to building designers for the mini- misation and prevention of possible adverse health effects of IEQ on building occupants. MEtHoDS The research was carried out in 17 randomly selected children daycare centres (anonymised and denominated by letters A–R) located in Slove- nia, which included 24 playrooms intended for children aged 3 to 5. The research took place at the targeted DCCs from March to June 2013. L. Pajek, M. Košir, M. DovjakIndoor environmental quality (IEQ) in Slovenian children daycare centres. Part II: The interrelationship... In the last three decades, an increasing number of studies have reported uncomfortable and unhealthy conditions in educational institutions. In the first place, the acquired knowledge would enable designers to have better control over potentially negative effects in future building renovations. © Inštitut za sanitarno inženirstvo, 201722  The methodology of the performed measurements and data preparation is presented in the first part of this study: Indoor environmental quality (IEQ) in Slovenian children daycare centres. Part I: Results of in-situ measurements. For the purpose of better interpretation of results, basic building characteristics of the analysed facilities are once more presented in Table 1. Buildings A, C and E were three out of 118 buildings in Slove- nia originally constructed for purposes other than ECEC (residential build- ings) and later adapted and used as DCCs. All other buildings included in the analysis were purposely designed and built as DCCs between 1963 and 2013. Among the analysed facilities, two were constructed in the last 10 years (i.e. P and R, 2012 and 2013, respectively) and were de- signed as low energy buildings. All other DCCs were constructed before the 1963. table 1: Basic information and building characteristics of selected DCCs Daycare centre Year of construction Recent renovationb Playroom no. Playroom occupation (children + staff) Floor area [m2] Floor area per occupant [m2/occ] volume [m3] Area of windows [m2] orientation of majority of windows, azimuth [°] A 1952 yes A1 14 + 2 35.7 2.2 102.2 7.3 W, 290 A2 20 + 2 35.8 1.6 112.2 10.3 W, 290 B 1979 yes B1 19 + 2 52.7 2.5 155.5 16.8 W, 292 C 1899 yes C1 14 + 2 35.2 2.2 131.5 11.5 E, 100 D 1963 No D1 18 + 2 44.6 2.2 161.1 20.8 NW, 310 D2 16 + 3 37.2 2.0 116.8 15.5 S, 178 D3 16 + 1 46.9 2.8 142.6 13.8 SE, 130 E 1906 No E1 14 + 2 36.3 2.3 127.4 3.3 W, 275 F 1979 No F1 19 + 3 39.0 1.8 116.5 14.8 E, 100 G 1979 yes G1 14 + 2 41.9 2.6 151.7 10.0 S, 160 G2 14 + 2 36.0 2.3 164.2 13.1 SE, 150 H 1976 yes H1 16 + 2 44.6 2.5 133.8 16.7 SW, 210 I 1973 yes I1 18 + 2 43.7 2.2 128.6 15.0 SE, 142 J 1982 No J1 20 + 2 33.8 1.5 113.3 11.5 SE, 128 J2 15 + 2 32.9 1.9 111.0 11.8 S, 149 K 1976 yes K1 18 + 2 38.2 1.9 99.4 10.7 E, 80 K2 21 + 2 46.8 2.0 145.9 13.4 SE, 128 L 1976 No L1 20 + 2 41.0 1.9 132.8 18.4 S, 172 M 1979 No M1 14 + 3 42.4 2.5 122.1 9.9 SW, 220 N 1971 No N1 17 + 2 50.3 2.6 174.5 21.5 S, 180 O 1972 yes O1 13 + 2 44.7 3.0 134.1 11.6 S, 200 O2 17 + 2 49.1 2.6 146.3 13.2 S, 158 Pa 2013 No P1 21 + 2 39.2 1.7 118.0 17.3 S, 178 Ra 2012 No R1 17 + 2 43.6 2.3 132.2 15.4 S, 164 a Low-energy DCCs; b Energy retrofit: replacement of windows. All the required data were then collected and prepared for further inves- tigation. The data were directly transferred to MS Excel software envi- ronment, where a database was made and prepared for additional processing. The main purpose of the study was to analyse the interrelationships among the selected boundary conditions and IEQ parameters. In general, the selected boundary conditions of interest can be divided into two groups, namely building characteristics and environmental characteristics. L. Pajek, M. Košir, M. Dovjak Indoor environmental quality (IEQ) in Slovenian children daycare centres. Part II: The interrelationship... International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 23  The investigated boundary conditions of building characteristics were as following: the year of construction of building, playroom volume, playroom volume/occupant, ventilation mode (natural or mechanical), window ori- entation and window to flor ratio (WFR), and whether the DCC has been energy retrofitted or not. Comparatively, the investigated boundary condi- tions of environmental characteristics were the number of playroom occu- pants and outdoor air temperature. In addition, it was investigated wheth- er the replacement of windows, as an energy renovation measure, has any impact on IAQ (i.e. concentration of CO2) or not. Beside the studied correlations between the selected boundary conditions and IEQ parame- ters, the potential correlation between different IEQ parameters was in- vestigated as well. RESultS AnD DISCuSSIon Although many of the possible correlations between the selected bound- ary conditions and IEQ parameters were investigated, the following sub- sections represent only several selected results. In the majority of cases the selected results represent the most significant findings, where po- tential correlation between studied IEQ parameters and boundary con- ditions can be drawn. Every field of IEQ is presented separately. thermal comfort Observing Figure 1, a weak correlation can be identified, showing that poorer thermal comfort conditions (higher percentage of people dissat- isfied with thermal comfort, i.e. PPD) can be recognised in newer DCC facilities. In this case, high PPD values were mostly the consequence of high indoor air temperatures in comparison to prescribed values. How- ever, this may be the result of higher outdoor air temperatures during the measurements in these facilities (Figure 2). The latter is even more apparent in the case of the two low-energy DCCs. Thus, it cannot be presumed that thermal discomfort in the investigated playrooms was necessarily a result of older building age. Similarly, in their study in Latvian DCCs Stankeviča and Lešinskis [19] reported that the tempera- tures were the highest in two newly-built DCCs that both had an under- floor heating system and a mechanical ventilation system, which is the same situation as for both low-energy DCCs (i.e. P and R) in the pre- sented paper. Nevertheless, Ruotsalainen et al. [20] reported the oppo- site trend in Finish DCCs, where indoor air temperatures and the corre- sponding thermal comfort were on average significantly lower in older buildings, which were, however, mechanically ventilated. The findings presented in Figure 2 show that PPD values grow with the increase in outdoor air temperature, which indicates a presence of cor- relation between PPD and outdoor air temperature. This may be the re- sult of non-existent cooling system in the selected facilities, which oper- ate in a free run mode during cooling season. Furthermore, thermal comfort in mechanically ventilated facilities strongly deviated from that in facilities with natural ventilation, especially in playroom R1 with PPD value of 29%. Inappropriate design or use of mechanical ventilation L. Pajek, M. Košir, M. DovjakIndoor environmental quality (IEQ) in Slovenian children daycare centres. Part II: The interrelationship... The findings presented in Figure 2 show that PPD values grow with the increase in outdoor air temperature, which indicates a presence of correlation between PPD and outdoor air temperature. © Inštitut za sanitarno inženirstvo, 201724  Figure 1: Percentage of people dissatisfied with thermal comfort (PPD) in all the considered playrooms compared with the building’s year of construction. Roman numbers I, II and III represent classes of thermal comfort defined in EN 15251:2007. Figure 2: Percentage of people dissatisfied with thermal comfort (PPD) in all the considered playrooms compared with the average outdoor air temperature during measurements. Roman numbers I, II and III represent classes of thermal comfort defined in EN 15251:2007. L. Pajek, M. Košir, M. Dovjak Indoor environmental quality (IEQ) in Slovenian children daycare centres. Part II: The interrelationship... International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 25  system could be one of the possible causes for thermal discomfort. As mentioned in Part I of the study, the highest CO2 concentrations were also identified in playroom R1, which has an above average floor area per occupant ratio (Table 1). Therefore, high CO2 concentrations are probably related to building characteristics or building use. Indoor air quality (IAQ) In the context of indoor air quality, the first correlation investigated was the correlation between the percentage of people dissatisfied with in- door air quality (PPDIAQ) and the volume of playroom per occupant. The latter has in general a considerable impact on IAQ, since greater volume of air means that there is more breathing air available per occupant. The volume of playroom per occupant varied between 4.97 m3/occ in playroom K1 and 10.26 m3/occ in playroom G2, which had the great- est ratio, while the average value is 7.22 m3/occ. However, playroom G2 was among playrooms with the worst IAQ (highest concentrations of CO2 were measured). The results in Figure 3 show that, surprisingly, there is no obvious correlation between the volume of playroom per oc- cupant and the predicted percentage of dissatisfied with indoor air qual- ity. Therefore, because indoor concentration of CO2 is also directly con- nected to the volume of indoor air, it can be said that other influential parameters have much greater effect on IAQ than the volume/occupant ratio. One of such parameters is definitely occupants’ behaviour. In this study, the latter is investigated through a search for the correlation be- tween PPDIAQ, temperature of outdoor air and teachers’ behaviour (i.e. decision to open a window or not) in Figure 4. Similar to the interpretation of PPD values in Figure 2, PPDIAQ values in the investigated DCCs (Figure 4) show a probable dependence on out- door air temperature as well. The trend is evident for the playrooms with natural ventilation, since the teachers in these playrooms opened win- dows or doors towards the outside (i.e. they naturally ventilated the play- room) more often, when the outdoor air temperatures were higher. No evident connection can be identified in the cases with mechanical ventila- tion system, as such systems are usually programed to ventilate rooms at a constant rate. However, it can be concluded that naturally ventilated playrooms had better IAQ than the ones with mechanical ventilation (low- energy DCCs). This is more apparent when observing the PPDIAQ value in the case with mechanical ventilation in relation to the other naturally ven- tilated playrooms with the same outdoor temperature (about 20°C) (Fig- ure 4). In this instance, the PPDIAQ of mechanically ventilated DCCs was approximately 10 percentage points higher than in the case of naturally ventilated ones. The trend line in Figure 4 presents the connection be- tween PPDIAQ and external air temperatures for naturally ventilated play- rooms. It was generated according to the conducted measurements, but excluding the values for playrooms D1, I1 and J1 (marked with doted el- lipse). The measured values for the stated playrooms greatly diverge from the trend evident in other naturally ventilated playrooms, due to external causes connected to the use of the rooms. Comparison of playrooms in the same DCC facilities (i.e. D2 to D1 and D3 as well as J1 to J2) shows L. Pajek, M. Košir, M. DovjakIndoor environmental quality (IEQ) in Slovenian children daycare centres. Part II: The interrelationship... In the context of indoor air quality, the first correlation investigated was the correlation between the percentage of people dissatisfied with indoor air quality (PPDIAQ) and the volume of playroom per occupant. © Inštitut za sanitarno inženirstvo, 201726  Figure 3: Percentage of people dissatisfied with indoor air quality (PPDIAQ) in all the considered playrooms compared with the volume of playroom per occupant. Roman numbers I, II and III represent classes of indoor air quality defined in EN 15251:2007. Figure 4: Percentage of people dissatisfied with indoor air quality (PPDIAQ) in all the considered playrooms compared with the average outdoor air temperature during measurements. Roman numbers I, II and III represent classes of indoor air quality defined in EN 15251:2007. Trend line was calculated only for playrooms with natural ventilation, excluding playrooms D2, I1 and J1, marked with dots. L. Pajek, M. Košir, M. Dovjak Indoor environmental quality (IEQ) in Slovenian children daycare centres. Part II: The interrelationship... International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 27  that the high values of PPDIAQ are probably the cause of occupant interac- tion with the built environment (e.g. teachers opening windows only when the children left the playroom due to the institutional internal rules as in the case of playroom I1). In other cases the reason why the playrooms were inadequately ventilated by teachers was in the external environ- ment, as in the case of D2 when due to the mowing of the lawn the win- dows were kept shut during the conducted measurements in order to block high levels of external noise (Leqe = 75 dB). Although the majority of the playrooms used natural ventilation as a ventilation mode, poor IAQ was still identified in several such cases. Teachers were reluctant to open windows or doors to naturally ventilate playrooms when outdoor temperatures were low or precipitations were present. Similarly, Cano et al. [21] noticed that teachers seldom open windows when outdoor temperatures are low, while Andersen et al. [22] and Dubrul [23] showed that occupants in general open windows more often and for longer periods during sunny weather. Correspond- ingly, since opening of windows in such situations cannot provide the optimal indoor conditions, Stankeviča and Lešinskis [19] recommended the use of a more efficient ventilation system (i.e. mechanical). Never- theless, in order to ensure the highest level of hygienic conditions, regu- lar maintenance and supervision of such systems is necessary. However, since mechanical ventilation can have its benefits (i.e. is occu- pant independent), a number of parameters influence its functioning as well. The latter can again result in poor IAQ, if the ventilation regime is not properly designed or its continuous maintenance is not performed. Hence, it was of further interest, if there are any differences in the IAQ of old, renovated or mechanically ventilated facilities. On the basis of Figure 5 it can be assumed that energy renovation of DCC facilities (i.e. replace- ment of windows) that were naturally ventilated had a negative impact on IAQ. The higher CO2 concentrations in renovated DCCs are probably the Figure 5: Median values and mean maximal values of CO2 concentrations, measured in the considered playrooms, divided in three different categories: playrooms with natural ventilation w/ (N=12) or w/o (N=10) recent renovation (i.e. replacement of windows) and playrooms with mechanical ventilation (N=2). L. Pajek, M. Košir, M. DovjakIndoor environmental quality (IEQ) in Slovenian children daycare centres. Part II: The interrelationship... Although the majority of the playrooms used natural ventilation as a ventilation mode, poor IAQ was still identified in several such cases. Teachers were reluctant to open windows or doors to naturally ventilate playrooms when outdoor temperatures were low or precipitations were present. © Inštitut za sanitarno inženirstvo, 201728  Figure 6: Mean daylight illuminance of working plane (E) in all the considered playrooms compared to the WFR. Playrooms are classified by the sky condition in three classes: overcast, intermediate and clear sky. The solid trend line is calculated for playrooms with overcast sky conditions, the dashed trend line for those with intermediate sky conditions. result of new windows, which are better sealed and thus the uncontrolled infiltration of external air is lower. Nevertheless, the occupants’ air venti- lation habits remain the same as before the renovation. Therefore, it is essential to assess the potential impact of the performed energy renova- tion measures on indoor environmental quality in DCC facilities. Moreo- ver, the staff (e.g. teachers, managers, janitors) should be informed and educated about the consequences of executed energy renovations in or- der to adjust their behaviour appropriately. Unexpectedly, the measured CO2 concentrations in new low-energy DCCs with mechanical ventilation systems were also quite high. This is probably the result of inappropriate- ly designed ventilation system and of thoughtless wish to achieve greater energy savings of building, ignoring IEQ at the same time. Nonetheless, in some investigated playrooms the teachers noticed poor IAQ conditions by themselves as well. visual comfort The trend of the insufficiently naturally lit playrooms can be to some degree related to the external weather conditions, as insufficient illumi- nance of the work plane was mostly recorded during overcast sky con- ditions (Figure 6). Overcast sky conditions were present in 77% of measurements in the analysed playrooms where the average work plane illuminance was below the 300 lx threshold. On the other hand, as ex- pected, the playrooms with larger areas of transparent elements (i.e. windows) exhibited higher levels of indoor illuminance. This can be seen from the trend lines generated for overcast and intermediate sky condi- tion measurements presented in Figure 6. However, this relationship between indoor illuminance and building en- velope configuration is also dependent on the orientation of the win- dows, as it can be observed from the results measured during clear sky conditions (Figure 6), where larger windows do not necessarily mean L. Pajek, M. Košir, M. Dovjak Indoor environmental quality (IEQ) in Slovenian children daycare centres. Part II: The interrelationship... Nevertheless, the occupants’ air ventilation habits remain the same as before the renovation. International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 29  better indoor visual comfort [24, 25]. High values of indoor illuminance can also cause occupant discomfort. Therefore, they represent a source of dissatisfaction with indoor visual environment, mainly due to the oc- currence of glare. An upper limit of 2000 lx (Figure 6) for average in- door illuminance was set in the conducted analysis on the basis of Use- ful Daylight Illuminance metrics proposed by Nabil & Mardaljević [26, 27], where horizontal illuminance levels above this value indicate higher level of glare occurrence [28]. Only one case (i.e. R1) exhibited average values above 2000 lx during the time of conducted measurements. However, this does not mean that in other cases localized parts of the playrooms were not illuminated above the upper threshold. Acoustic comfort Although potential links between noise level and building characteristics were investigated, no specific correlations were found. Thus, the number of children in playrooms or the volume of playroom per occupant had no evident effect on the measured noise levels. Moreover, no clear association was detected between the noise level in the playrooms and other types of discomfort. Specifically, no correlation was identified between the meas- ured equivalent noise level and PPD (Figure 7) or PPDIAQ, where it was speculated that children would make more noise when dissatisfied with the thermal comfort or the quality of indoor air. Notably, Figure 7 clearly illustrates that for the selected sample of playrooms, no evident correlation between noise level and PPD can be identified, since playrooms with the worst PPD (e.g. playroom R1), were not necessarily also the noisiest. However, no correlation between the parameters of acoustic comfort and other investigated parameters was identified during the conducted analy- sis. Although this may be the case, the phenomenon is worth of further investigation in order to identify whether the connection exists or not. Figure 7: Percentage of people dissatisfied with thermal comfort (PPD) in all the considered playrooms compared with the average measured noise level. Roman numbers I, II and III represent classes of indoor air quality defined in EN 15251:2007. L. Pajek, M. Košir, M. DovjakIndoor environmental quality (IEQ) in Slovenian children daycare centres. Part II: The interrelationship... © Inštitut za sanitarno inženirstvo, 201730  StuDY lIMItAtIonS Although this research was carefully prepared, we are aware of its limi- tations. One of the greatest limitations is the sample size of the ana- lysed children daycare centres. Because the sample of 24 playrooms is relatively small, no certain statistical correlation can be determined. However, the identified relationship between the studied IEQ parame- ters and environmental boundary conditions was in some cases weak or even non-existent (e.g. acoustic comfort), while in other instances it was strong (e.g. relationship between PPDIAQ and external air tempera- tures). Even though some of the presented results probably do point to a trend connecting certain studied parameters, they should still be used with caution due to a small sample of buildings and varied environmen- tal conditions encountered during the conducted measurements. Fur- thermore, in order to get more accurate results, IEQ parameters should be monitored and measured through a longer time span. For instance, monitoring of IEQ parameters should be conducted during several months, preferably including both heating and cooling season and for the entire period of occupied hours of DCC. Another limitation of the study is that there is not enough prior research available in the field of indoor environmental quality in Slovenian chil- dren daycare centres. Consequently, there are no or very few available data to, for example, compare IEQ in the same facility before and after the executed energy renovation. Therefore, further research in this field is highly encouraged. ConCluSIonS Occupants play a key role in the design of buildings and their indoor environment, especially if they are a vulnerable population (e.g. chil- dren). However, initial design decisions on the level of building envelope largely influence further response of a building, as shown by Hudobivnik et al. [13] and Pajek et al. [29]. Therefore, thoughtful design decisions should be encouraged, because designers rarely holistically analyse the building behaviour before it is put into use. In addition, the potential negative impacts of energy renovation of buildings on IEQ have to be taken into account, where the wish for smaller energy use in buildings in most cases dominates over other design criteria [11]. Similar conclu- sions were shown by Perino et al. [30] for residential buildings, where energy renovations had a negative impact on IAQ. Consequentially, it can be assumed that in DCC facilities this problem could be even more pronounced (Figure 5) due to higher occupant density. Thus, it is on one hand necessary to understand how the energy renovation meas- ures will influence the indoor environment and on the other to educate the occupants how to use the renovated building, as higher levels of building envelope’s air tightness will result in lower air changes and consequentially lower IAQ. This was already identified by Langer and Bekö [31], reporting that newer buildings were characterised by lower air change rates and therefore higher levels of indoor pollutants. Never- theless, outdoor air quality also has an evident impact on indoor envi- L. Pajek, M. Košir, M. Dovjak Indoor environmental quality (IEQ) in Slovenian children daycare centres. Part II: The interrelationship... Even though some of the presented results probably do point to a trend connecting certain studied parameters, they should still be used with caution due to a small sample of buildings and varied environmental conditions encountered during the conducted measurements. In addition, the potential negative impacts of energy renovation of buildings on IEQ have to be taken into account, where the wish for smaller energy use in buildings in most cases dominates over other design criteria. International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 31  ronment and should be considered as well [32]. In the case of buildings with mechanical ventilation system applied, the design and use of the system should be occupant-requirement based and not influenced only by the energy-saving potential of lower ventilation rates. This is very important, because mechanical systems are more user independent than natural ventilation, which can be manually regulated by the occu- pants according to their needs and wishes. Acknowledgements This study was conducted in collaboration with the selected children daycare centres in Slovenia. 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Part II: The interrelationship... © Inštitut za sanitarno inženirstvo, 2017 International Journal of sanitary engineering researchVol. 11  No. 1/2017 S it r Engineering Research 33 use of a nudge tool for improving hand hygiene in a nursing team in home for elderly people – case study Tjaša MlAkAR1, Andreja MIhElIč ZAJEc1, Mojca JEvšnIk2* ABStRACt The prevention and control of healthcare-associated infections are one of the most important indicators of quality in healthcare institutions and their employees. For this purpose, experts in this field are attempting to find improvements; one of them is called “nudging”. This study aims to present the importance of providing hand hygiene quality in nurses and to analyse the effectiveness of a selected nudging tool in practice. An observation checklist was made to evaluate nurses in a selected nursing home in Ljubljana. Based on data analysis, a picture of male eyes as hygiene promotion and how it affects the change in hygiene compliance of the nurses was tested. After a change in the environment, hand hygiene improved; the greatest improvement was seen prior to the preparation of devices for personal hygiene, before the procedure, after washing the patient’s face, body, back and hands, after washing the feet, and after the whole procedure was completed. With the use of behavioural theories, better hand hygiene compliance can be achieved. It can be concluded that nudging may help us prevent and control healthcare-associated infections and provide a higher quality of life for residents and, consequentially, improve the quality of nursing care. key words: nursing care, hand, hygiene, elderly, behaviour, employees 1 University of Ljubljana, Faculty of Health Sciences, Nursing department, Zdravstvena pot 5, Ljubljana, Slovenia 2 University of Ljubljana, Faculty of Health Sciences, Department of sanitary engineering, Zdravstvena pot 5, Ljubljana, Slovenia * Corresponding author Mojca Jevšnik, University of Ljubljana, Faculty of Health Sciences, Department of sanitary engineering, Zdravstvena pot 5, Ljubljana, Slovenia E-mail: mojca.jevsnik@zf.uni-lj.si Received: 12. 12. 2017 Accepted: 19. 12. 2017 Original scientific article  © Inštitut za sanitarno inženirstvo, 201734  IntRoDuCtIon The elderly represent a large and increasing segment of the population throughout the world. According to the EUROPOP2008 population pro- jections, people older than 79 are expected to triple in number by 2060, and since long-term care begins to rise exponentially at around 75 to 85 years of age, rapid growth in demand for such service is inevi- table for the next fifty years or so [1]. Because of their age, illness, mo- tor disability, general weakness, and dementia, more and more of the elderly live in nursing homes. Healthcare-associated infections (HCAI) are very common and are one of the most widespread adverse events in healthcare. HCAI not only bring financial costs, but extend hospitali- zation, make a significant contribution to patient mortality, and to per- manent disability. Prevention and control of HCAI is one of the most important elements for providing patient safety and an indicator of the work quality among nurses and homes for the elderly [2, 3]. Hand hy- giene is considered the most important intervention to prevent and con- trol the spread of HCAI. Nurse’s hands are the most common means of transferring microorganisms from the colonized, infected patient, and his environment to other patients. Inconsistent hand hygiene is present in all environments, in the developed and developing worlds and in all profiles of healthcare professionals. The reasons for the inconsistency are many and dependent on the environment, infrastructure, cultural differences and even religion [4]. Numerous research studies state that lack of experience, overburdened schedules, heavy workloads, lack of knowledge and insufficient washing basins are reasons for poor hand hygiene among nurses in the nursing homes. In most cases, hand hy- giene is previously used to protect nurses, rather than to protect resi- dents, because the compliance of hand hygiene is higher after contact with the patient than before. More nurses provide better hand hygiene after contact with body fluids in comparison to other forms of contact with the residents or their surroundings [5]. Experts for providing and controlling HCAI are striving to eliminate fac- tors that contribute to poor hygiene of the hands. One current method of improving hand hygiene compliance is called nudging [6]. The idea originates from economics, but it can be used in many areas, including nursing care. It is about behaviour that can be influenced by subcon- scious cues in the environment, such as sights, smells, and sounds. Nudging acts outside of our conscious awareness and influences our behaviour and cognition. By using the elements of nudging, better re- sults in the field of hand hygiene compliance can be achieved, which, in theory, leads to reducing the incidence of HCAI [7, 8]. The main rea- sons for using nudging in healthcare are to improve public health (en- couraging healthy eating habits, regular physical activity, less smoking, less stressful lifestyle, reducing body weight, etc.); reducing the need for treatment, which is a great expense and, finally, an improvement in the quality of life during hospitalization or living in nursing home [9]. In this way, some hospitals in America have attempted to improve their employee’s hygiene. As a nudge, a clean, fresh citrus smell, which came from an aroma dispenser, was used, accompanied by a photograph of T. Mlakar, A. Mihelič Zajec, M. Jevšnik Use of a nudge tool for improving hand hygiene in a nursing team in home for elderly people – case study Healthcare-associated infections (HCAI) are very common and are one of the most widespread adverse events in healthcare. Prevention and control of HCAI is one of the most important elements for providing patient safety and an indicator of the work quality among nurses and homes for the elderly. International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 35  male eyes that was prominently displayed above the alcohol dispenser. The results have shown that people exposed to these specific cues had better hand hygiene compliance [7, 8]. There are other ways to improve hand hygiene compliance. Which alco- hol dispenser in the corridor of the hospital is mostly used was ob- served. Above the dispensers, signs were placed that defined dispens- ers from the least used (5th place) to the most used (1st place). After these signs were installed, alcohol dispensers were used 250% more frequently than before [10]. A similar study was made at the Gentofte Hospital in Denmark. The nudge consisted of three parts: placement, colour, and normative message. Researchers spent five days watching the frequency of the visitor’s hand disinfection. In the Medical Depart- ment, alcohol dispensers were primarily located above the sinks inside the hospital wards. The choice of using hand sanitizer is thus offered at a seemingly late point in time, competing against the choice of ap- proaching one’s hospitalized relative. For this purpose, they introduced a freestanding alcohol dispenser at the entrance the Medical Depart- ment. Disinfectants and dispensers are usually transparent, which made them blend into the surrounding environment. The researchers, there- fore, introduced a red sign right above the freestanding dispenser. The last prime was the text message printed on that red sign: “Here we use hand disinfectant in order to protect your relatives”. The first part of the text (“Here we use hand disinfection”) informs visitors about the most acceptable behaviour in relation to hand hygiene at the hospital. The second part of the text (“in order to protect your relatives”) was used to make the consequences of hand hygiene compliance more tangible to visitors by giving them a plausible reason as to why they should engage in positive hand hygiene behaviour. The results indicate that the visitor’s hand hygiene compliance, after the introduction of the freestanding al- cohol dispenser, increased up to 17%, and after putting the red sign above the freestanding dispenser, up to 64%. The research was not in- tended for nurses but for hospital visitors, but the same environmental cues could also be used among hospital employees [11]. Hand hygiene compliance can also be influenced by technological pro- moters. One example is an LCD TV screen which shows what percentage of people washed their hands after using the toilet [12]. The next exam- ple is the BIOVIGIL device, which aims to exploit emotional embarrass- ment. The BIOVIGIL system uses traffic-light colours: green, yellow and red. It works in conjunction with a badge clipped to workers’ shirts, which communicates with infrared sensors put in patient’s rooms. When the physician or nurse washes his/her hands, they hold them up to the badge’s sensors, which will determine whether they are germ-free. If they are, the badge turns green, but if they are not, it turns red. This reminds the patient that a physician or a nurse with dirty hands will touch him. This encourages hospital employees to take care of hand hygiene, as no- body wants to walk around wearing a red badge [13, 14]. Hand hygiene compliance can also be influenced by the visibility and ac- cessibility of alcohol dispensers. Most studies recommend the installation of alcohol dispensers at the entrances and exits to the patient’s room and T. Mlakar, A. Mihelič Zajec, M. JevšnikUse of a nudge tool for improving hand hygiene in a nursing team in home for elderly people – case study Researchers spent five days watching the frequency of the visitor’s hand disinfection. Hand hygiene compliance can also be influenced by the visibility and accessibility of alcohol dispensers. © Inštitut za sanitarno inženirstvo, 201736  its surroundings, and near the toilets [15]. The next visual cues were im- ages of bacterial growth designed to motivate hospital staff to comply with hand hygiene regimes. They took 10 samples from the medical staff’s hands and then showed them pictures of cultures similar to the contamination on their hands. In a very short time, their hand hygiene compliance increased, which proves that visual triggers are an effective way to motivate nurses and other healthcare providers to clean their hands more often [16]. Automatic dispensers for paper towels in public toilets have been installed to stimulate hand washing, which present a towel with or without user activation. The use of towels was 22.6% high- er and the use of soap 13.3% higher [17]. Visual cues also include signs at the door before entering the room. On a piece of paper, the following was written in red: “Warning, this room is under constant supervision of hand hygiene. An error will trigger an alarm, and the violation will be re- ported.” This nudge has been the most successful of all [18]. This research aims to present the importance of ensuring the quality of hand hygiene (with emphasis on hand disinfection) of employees in nursing care and analyses the effectiveness of a selected nudging tool in daily practice among selected nurses. MEtHoDS Between October 2016 and February 2017, a literature review on the COBIB.SI, Medline (PubMed), CINAHL, Cochraine and Web of Science databases over a ten-year period (2007–2017) was performed. An inter- vention study has been made. For the data collection regarding the hand disinfection of eight nurses, an observation checklist was made. Criteria for observing the hand disinfection were determined on the basis of standards of nursing activity [19]. The process of hand hygiene was ob- served, with an emphasis on hand disinfection. In the measuring instru- ment (observation checklist), the first column listed the opportunities for hand disinfection (i.e. procedures from the beginning of the personal hy- giene procedure to the end, in sequence). Afterwards, whether the nurse performed the hand disinfection properly and in accordance with the standards or not was marked. Does she or he use a sufficient amount of disinfectant (3 ml or two pushes on the dispenser), does hand disinfec- tion last at least 20 s, or disinfect all areas of the arm in the prescribed order (palms, fingers, middle areas and back of the hand) and disable transmission of microorganisms from one part to another [20]? In the ob- servation checklist, there was also a space for observer comments on the conditions during the observation. The last column in the observation checklist was intended to indicate the disturbing and warning factors that remind or deter the observed nurse from acting correctly (e.g. observer presence, full hands, dry and damaged skin of the observed, too much work, forgetfulness, less probability of transmission of infection, disagree- ment with recommendations, lack of information, thinking that after using gloves, it is not necessary to disinfect the hands, jewellery and long nails, which does not provide correct hand hygiene compliance, call of patient / colleague / physician and personal beliefs). T. Mlakar, A. Mihelič Zajec, M. Jevšnik Use of a nudge tool for improving hand hygiene in a nursing team in home for elderly people – case study They took 10 samples from the medical staff’s hands and then showed them pictures of cultures similar to the contamination on their hands. Afterwards, whether the nurse performed the hand disinfection properly and in accordance with the standards or not was marked. International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 37  The observation process took place in a nursing home in Ljubljana from 30 January to 1 March 2017. For the purpose of the observation proc- ess, we selected eight nurses, at the nursing care workplace, based on previously obtained consent, from the director of the observed Home for Elderly People. Data processing and names of the selected nurses were anonymous. Three observations per day were carried out, from 7 am to 9 am in the morning shift, in the implementation of personal hygiene of two or three residents. Each nurse was observed throughout the entire work process, but not all the eight observed were observed for equal amounts of time, due to the different working schedules. At the time of observation, notes were made in the observation checklist. The first phase of observation process was carried out without the selected nudge tool, and the second phase was performed with the selected nudge tool (picture of male eyes above the alcohol dispensers). All im- ages were coloured, with dimensions of 6 × 17 cm. Both phases last 14 days. This was followed by a re-analysis of data and a comparison of the results of the first and second observations. The acquired data were processed using MS Excel software. Frequencies and ratios were calculated according to the equation (E1) [21]. A summary presentation of the results was presented in a diagram, and the most common rea- sons for abandonment or improper hand disinfection were represented. Consideration of hand hygiene = number of actual × 100 number of occasions RESultS AnD DISCuSSIon There were 75 observations of hand disinfection of 8 nurses in the nurs- ing team without nudging, and then another 75 observations of hand dis- infection with nudging. Eight observers represent 16% of all employees in the nursing team. Table 1 shows the results of observing hand disinfec- tion without nudging, with it, and the causes of noncompliance in hy- giene behavior. Since all of the eight observed were not observed at the same time and since each of the observed was observed several times a day and several days in a row, the object of the observation is not the number of people who have properly disinfected their hands, but the number of hand disinfection observations. The most correct hand disin- fections were performed at the seventh criterion (putting the new gloves on and performing anogenital care; after this is done, gloves are taken off, and hands are disinfected). In 71 observations, the observed nurse disinfected his/her hands correctly. Hand hygiene compliance was also good at the third criterion (i.e. use of gloves immediately before washing areas that are dirty with blood, secretions, saliva, washing the anogenital area and legs; after use of gloves, hands are disinfected). At 67 observa- tions, the nurse observed disinfected his/her hands correctly. At the sixth criterion (i.e. changing the water, disposable washbasin and clothing, fol- lowing which hands are disinfected) disinfection was done the least or al- most never, because this procedure, followed by hand disinfection, was not executed. At a nursing home, nurses do not put the lotion on resi- dents’ skin after personal hygiene is made, they do not change the water T. Mlakar, A. Mihelič Zajec, M. JevšnikUse of a nudge tool for improving hand hygiene in a nursing team in home for elderly people – case study The first phase of observation process was carried out without the selected nudge tool, and the second phase was performed with the selected nudge tool. At a nursing home, nurses do not put the lotion on residents’ skin after personal hygiene is made, they do not change the water for each resident, and gloves are rarely changed. © Inštitut za sanitarno inženirstvo, 201738  for each resident, and gloves are rarely changed. In addition, hand disin- fection was worse at the fourth criterion (i.e. washing the patient’s face, body, back and hands, followed by hand disinfection). The observed nurses disinfected their hands in 37 observations at the fourth criterion. After completing the first part of the observation, a tool to promote hand hygiene compliance (picture of male eyes above the alcohol dispensers), was introduced, and then the entire procedure of hand disinfection was observed again. The most compliant observed nurse disinfected his/her hands in accordance with the seventh criterion (i.e. putting the new gloves on and performing anogenital care, following which, gloves are taken off, and hands are disinfected). At the seventh criterion, there were 71 observations. It was established that the observed nurse disinfected his/her hands correctly. The eighth criterion (i.e. gloves are put on again, the lotion is put on the residents and hands are disinfected) was ob- served the least or almost never. The results are shown in Table 1, in which 100% means that the observed nurse correctly disinfected his/her hands 75 times out of 75 opportunities. table 1: Results of hand disinfection observation at the observed nursing team, during the personal hygiene procedure and reasons for non-accomplishment of hygiene requirements Criterion of observation A (n) A Ratio (%) B (n) B Ratio (%) Reasons for non-accomplishment of hand disinfection 1. Hand disinfection and preparation of the items for personal hygiene. 30 40 45 60 Forgetfulness, conversation with an employee rush, dry skin, observed nurse did not disinfect all areas of his/her hands, insufficient amount of disinfectant and too fast disinfection. 2. Hand disinfection before the personal hygiene procedure. 56 75 61 81 Less possible infection transmission dry skin, rush, too fast disinfection, conversation with an employee, insufficient amount of disinfectant, forgetfulness, the observed nurse did not disinfect all areas of his/her hands. 3. use of gloves before washing the areas that are dirty with blood, secretions, salvia; at washing anogenital area and legs. After their use, hands are disinfected. 67 89 67 89 Rush, conversation with the resident, the observed nurse did not disinfect all parts of his/her hands, too quick disinfection and insufficient amount of disinfectant. 4. Washing the patient’s face, body, back and hands, followed by hand disinfection. 37 49 39 52 Conversation with resident, forgetfulness, rush, too quick disinfection, dry skin, insufficient amount of used disinfectant and the observed nurse did not disinfect all areas of his/her hands. 5. Clean gloves are put on. the legs are washed. gloves are taken off, and hands are disinfected. 52 69 55 73 Forgetfulness, full hands, conversation with an employee, too quick disinfection not enough of disinfectant, rush, the observed nurse did not disinfect all areas of his/her hands. 6. Water, washbasin and the clothes are replaced and, after this, hands are disinfected. 0 0 0 0 The procedure was not accomplished because of the rush. 7. new gloves are put on, and anogenital area is washed. gloves are taken off, and hands are disinfected. 71 95 71 95 Rush, the observed nurse, did not disinfect all areas of his/her hand, full hands and conversation with the resident. 8. gloves are put on. lotion is spread on the resident and hands are disinfected. 6 8 0 0 The procedure was not accomplished because of the rush. 9. After the whole procedure is done, the hands are disinfected. 61 81 63 85 Less disinfectant used, the observed nurse did not disinfect all areas of his/her hand, forgetfulness and full hands. Legend: A – correct hand hygiene observation without nudging; B– correct hand hygiene observation with nudging; (n – number of observation; % – ratio T. Mlakar, A. Mihelič Zajec, M. Jevšnik Use of a nudge tool for improving hand hygiene in a nursing team in home for elderly people – case study International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 39  At the observation process without the use of the selected nudging tool, there were 675 opportunities for hand disinfection. Correct hand hy- giene of the observed nurses was conducted 380 times, of which 295 times were done incorrectly. Figure 1 shows the reasons why the ob- served nurse did not correctly disinfect his/her hands. The most com- mon reason for this was that the procedure followed by the hand disin- fection was not made. The least common reason was when the hands of the observed nurse were full of resident’s laundry and hygiene sup- plies. During the observation process with the selected nudge tool, there were 675 opportunities for hand disinfection. Correct hand hygiene of the observed nurses was conducted 401 times, and 274 times it was not done so. Figure 2 shows the reasons that the observed nurse did not disinfect his/her hands. The most common rea- son for this was that the procedure followed by hand disinfection was not made. The least common reason was when the observed nurse’s hands were full of personal hygiene products and residents’ laundry. In the nursing home, because of the more frequent contact between the staff and residents, HCAI are more common. They contribute to the poorer quality of living in the institution. In the nursing home, the nurs- Figure 1: Reasons for non-accomplishment of hand disinfection without the nudge Figure 2: Reasons for non-accomplishment of hand disinfection with the nudge T. Mlakar, A. Mihelič Zajec, M. JevšnikUse of a nudge tool for improving hand hygiene in a nursing team in home for elderly people – case study © Inštitut za sanitarno inženirstvo, 201740  ing team plays a very important role in preventing the transmission of infections to residents, from the resident to the staff and from resident to resident via nursing care supplies and hand contact. With proper hand hygiene, transfer can be effectively prevented [22]. In the consid- ered nursing home in Ljubljana, they decided to record the data of the HCAI occurrence among the residents, in order to determine the quality of hand hygiene and on this basis plan further improvements [23]. They record the infections with MRSA and ESBL. In 2011 they had one HCAI, 2012 three, 2013 six, 2014 thirteen, 2015 nine, and 2016 sev- en (Table 2). The quality of nursing care is also assessed through the recorded occurrence of HCAI. Therefore, it is crucial that graduate nurs- es, as carriers of nursing care, determine the needs for the prevention of HCAI, plan and implement interventions for prevention, identify per- formers and, ultimately, evaluate the performed work and achieved nursing-care goals [2, 23]. table 2: Number of residents colonized with MRSA and ESBL from 2011 to 2016 in nursing home where research was done Year 2011 2012 2013 2014 2015 2016 MRSA 1 3 2 5 2 4 ESBl 0 0 4 8 7 3 One of the newer methods of preventing HCAI, and thus ensuring quali- ty in nursing care, is nudging, which, by applying behavioral theory, af- fects the behavior of employees. According to the literature review, the most effective promoters of hand hygiene behavior were: the citrus smell from air fresheners (hand disinfecting was improved by 32%), the image of male eyes above the disinfectant dispensers (hand disinfection improved by 18%), numbers 1 to 5 defining alcohol dispensers as the most or the least used (hand disinfection improved by 250%), a red sign above the alcohol dispenser (disinfection improved by 64%) and an automatic paper towel dispenser (disinfection improved by 22%). In this study, a visual cue was used to improve the hand hygiene of the ob- served nurses. The nudge tool was the image of male eyes that were placed above the disinfectants in the living room, in the corridor, in the bathroom and on the nursing cart (Figures 3, 4, 5). All images were in color, with dimensions of 6×17 cm [6, 7]. Among the residents, only two older women noticed them and asked the researcher about their meaning. On the first day of installation, the imag- es caused a lot of attention and interest among the employees in and out of the department. All the employees said that the pictures were awful, frightening, and they felt that they had constantly been observed. In the beginning, several days were spent observing the nurses without recording the results on the observation checklist, so that the nurses be- came accustomed to the presence of the researcher. Data recording then started. It was discovered that the observed nurses did not consider the prescribed hygiene standards of hand disinfection in the accomplishment T. Mlakar, A. Mihelič Zajec, M. Jevšnik Use of a nudge tool for improving hand hygiene in a nursing team in home for elderly people – case study International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 41  Figure 3: Picture of male eyes above automatic alcohol dispenser (Photo: Mlakar, 2017) Figure 4: Picture of male eyes next to the alcohol dispenser and the soap dispenser (Photo: Mlakar, 2017) Figure 5: Picture of male eyes at the alcohol dispenser on the wagon for personal hygiene items (Photo: Mlakar, 2017) of the entire personal hygiene process. They almost never disinfected their hands after changing the water and clothing and after putting the lotion on the resident, because the procedure followed by hand disinfection was not executed. Furthermore, disinfection of the hands was slightly worse after washing the face, body, back and hands, as the observed were in a hurry during the procedure and often forgot to replace the gloves and dis- T. Mlakar, A. Mihelič Zajec, M. JevšnikUse of a nudge tool for improving hand hygiene in a nursing team in home for elderly people – case study © Inštitut za sanitarno inženirstvo, 201742  infect their hands. Disinfection immediately before preparing personal hy- giene products was also a bit worse. Often the reason was forgetfulness and conversation with colleagues or students on practical training. Think- ing that hands are clean at the beginning of the day and disinfecting dam- aged hands can be painful, which deters the employees from disinfecting their hands again when they come to work.The most correct and precise hand disinfection was after the glove use, immediately after the contact with areas that were dirty with blood, secretions, and saliva, and washing the anogenital area. Hand disinfection was also good after the whole pro- cedure was finished. The results showed that the observed employees’ hand hygiene was the most precise after contact with the patient. More observed nurses attend proper hand hygiene after body fluid contact, compared to other contacts with the resident or his/her surroundings. At other recorded incomplete hand disinfection, employees in most cases used sufficient amounts of soap, but their hand disinfection was too short, or they did not disinfect all hand areas. Observer’s hands were without jewellery; nails were short and without nail polish. This is very important in preventing HCAI, as most microorganisms accumulate under long nails and under jewellery, with which good disinfection is very hard to provide. The reasons that the observed nurses did not disinfect their hands cor- rectly or did not disinfect them at all are tiredness, early morning hours, rush, distracted thinking and the observed simply forgot about the prop- er hand hygiene. This happened mostly during the hygiene product preparation and then during the process. Conversation with an employ- ee or a resident during the process often distracts the observed from the correct hand disinfection technique, because his/her attention is fo- cused on the conversation. For this reason, hand disinfection was su- perficial. The observed nurses spend less than 20 seconds for disinfec- tion, with not enough disinfectant (less than 3 ml or two pushes on the alcohol dispenser), or she/he does not disinfect all hand parts. Each health institution prescribes a regime of hand disinfection and hand washing techniques, which must be followed in the correct order so that all hand areas are disinfected (palms, fingers, middle spaces and back of the arms) [20]. One very common reason for the hand hygiene inconsistency was being rushed. In the observed nursing home ward, 20 immobile residents live. On a shift, only three nurses and two stu- dents of the health faculty in Ljubljana work there. Given the number of nursing procedures that the staff had to do, they had to hurry, so they could finish the work by breakfast, and then continued with bathing the patients and other procedures. This is a department with mostly resi- dents with dementia; consequently, performing personal hygiene lasts even longer because of the specific factors of movement, understand- ing, and communication. In addition, the employees need a lot of time to explain to the residents what they are going to do, and to obtain their cooperation and permission to carry out the procedure. The number of employees and overcrowded departments are two of the biggest prob- lems in the observed nursing home. The HCAI occurrence is inversely proportional to the number of health care providers [2]. Because the observation was executed in winter, many nurses had problems with dry and cracked skin, which made hand disinfection very T. Mlakar, A. Mihelič Zajec, M. Jevšnik Use of a nudge tool for improving hand hygiene in a nursing team in home for elderly people – case study The reasons that the observed nurses did not disinfect their hands correctly or did not disinfect them at all are tiredness, early morning hours, rush, distracted thinking and the observed simply forgot about the proper hand hygiene. International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 43  painful. Many had skin problems, not only because of the weather and season but also because of the daily multiple hand washing with soap and water. Therefore, the employees avoided hand disinfection, espe- cially when they thought that there was a minor possibility of infection transmission (during the preparation of the hand hygiene nudge tool). They did not change their gloves so they would not need to disinfect their hands [23]. Changing the water and putting the lotion on the resi- dent are two procedures that were almost never performed because of the rush and way of working in the nursing home. Therefore, there was no hand disinfection. During personal hygiene performance, it was also necessary to carry away the dirty laundry from the resident’s room (py- jamas, other clothes, and other items), because of which the observed nurse had full hands and, therefore, did not disinfect them. The reasons, from the most frequent to the least, that the observed nurse did not why he/she did not properly disinfect hands (or at all) dur- ing observation without the nudge are: forgetfulness, carelessness re- garding disinfection, rush, conversation with an employee or resident, damaged skin of the observed nurse, less likely infection transmission, and full hands. These are also the most common reasons that nurses have bad hygiene compliance. After the first part of the observation was finished, the nudge was intro- duced. It was determined that the hand disinfection before the prepara- tion of personal hygiene products was improved by 20%, before start- ing the procedure by 6%; after the glove use after washing the dirty areas with blood, secretions, saliva, washing the anogenital area and feet, the result remained the same; after washing the face, body, back and hands, hand disinfection improved by 3%, after washing the feet by 4%; after changing the water and washbasin, the result remained un- changed. Furthermore, after anogenital care, after putting on the lotion, and after the whole procedure of personal hygiene was done, hand dis- infection improved by 4%. In research studies [7, 8], the results show that employees who were exposed to triggers (picture of men’s eyes above the dispensers) had better hand hygiene compliance. It can be concluded that nursing staffs’ actions can be improved if they are ex- posed to specific cues. Therefore, nudging could be used as a way of preventing HCAI and as a new and better method for changing employ- ees’ behavior, with the purpose of improving the living quality of resi- dents in a nursing home [24, 25]. The main reason for incorrect hand hygiene compliance at the observa- tion with the nudge is in the first place the same as in the previous ob- servation: the procedure followed by hand disinfection was not execut- ed. The second reason is carelessness, followed by rush, forgetfulness, conversation with the resident or employee, skin damage of the ob- served nurse, less possible infection transmission, and full hands. As a reason for incorrect hand disinfection, forgetfulness moved from the second place to the fourth. It can be concluded that the visual cue had the strongest effect on this reason. More proper hand disinfection because of observer presence was not observed. There are students from a health faculty in Ljubljana present T. Mlakar, A. Mihelič Zajec, M. JevšnikUse of a nudge tool for improving hand hygiene in a nursing team in home for elderly people – case study During personal hygiene performance, it was also necessary to carry away the dirty laundry from the resident’s room. More proper hand disinfection because of observer presence was not observed. © Inštitut za sanitarno inženirstvo, 201744  throughout the year, and the staff is accustomed to their presence. Those who are consistent with personal hygiene procedures are also consistent with hand hygiene compliance. The employees in the observed nursing home ward are aware of the importance of good hand hygiene and are convinced that HCAI is a ma- jor problem in nursing care and healthcare in general. They also say that if there were more employees, they would also have more time for residents and provide better nursing care for each one. The nudge ac- complished its purpose, as the consistency of hand hygiene improved the most before the preparation of personal hygiene products, before starting the procedure, after washing the patient’s face, body, back and hands, after washing the legs, and after the whole procedure was done. In those procedures (after using gloves after washing areas that are dirty with blood, secretions, saliva, washing the anogenital region and legs) for which hand disinfection was good even before the introduction of the nudge, there was no difference. After the introduction of the nudge, hand hygiene improved the most at the beginning, during the preparation of the devices, compared to other stages of the personal hygiene procedure. The reason is that the observed nurse stayed the longest with the cart supplies, disinfectants, and the picture of men’s eyes above the disinfectant, while they were preparing personal hygiene items and the fact that there was the most noticeable difference in comparison to the previous poor hand disinfection. Alcohol dispensers were always full in the observed ward. One auto- matic alcohol dispenser was installed in the corridor, another in the din- ing room next to the washbasin, a third on the cart for hygiene items and a fourth in the bathroom next to the washbasin (Figure 1). This is a novelty that attracted a lot of attention in the nursing home among em- ployees, residents, and visitors. Depending on the amount of disinfect- ant in the alcohol dispenser, there was a greater consumption than with standard alcohol dispensers. Automatic disinfectants measure a suffi- cient or appropriate amount of disinfectant. They represent something technologically new, interesting, and are also very appealing. As with pictures above alcohol dispensers, they represent a nudge to promote hand hygiene behavior, using the latest technology. From this, it can be concluded that the observed nursing home is already using a new way of preventing the HCAI and thus provide high living quality of the resi- dents. This is also confirmed by the data. The number of residents with HCAI during the years of data recording is low, ranging from 0 to 13 (Table 2). The recording of the numbers of HCAI (MRSA and ESBL) started in 2011. ConCluSIon It is vital that residents in nursing homes feel well, comfortable, and safe and that there is the highest possible quality of living and nursing care. Quality is an indispensable and essential element of nursing care. Knowledge and considering prevention and control methods of HCAI is imperative for all healthcare providers because it prevents negative con- T. Mlakar, A. Mihelič Zajec, M. Jevšnik Use of a nudge tool for improving hand hygiene in a nursing team in home for elderly people – case study Quality is an indispensable and essential element of nursing care. International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 45  sequences, such as the social isolation of the resident, early death, and disability. Nurses in the observed nursing home partially consider the prescribed hygiene standards regarding hand disinfection. Observed nurses almost never disinfected their hands after changing the water, the clothes, and after putting the lotion on the resident because this procedure, followed by hand disinfection, was not executed. Moreover, hand disinfection was worse after washing the residents’ faces, bodies, backs, and hands, and before preparing personal hygiene items. The most correct and accurate was hand disinfection after use of the gloves, immediately after the contact of the areas that were dirty with blood, secretions, saliva, washing the anogenital area and after the working procedure was completed. After the implementation of the nudge, hand disinfection before the preparation of personal hygiene items, before the beginning of the procedure, after washing the patient’s face, body, back and hands, after washing the legs, and disinfection after the whole pro- cedure had been done improved the most. There was no difference af- ter nudging for the procedures for which disinfection was already per- formed well: after the use of gloves after washing the areas that were dirty with blood, secretions, saliva, and washing the anogenital region and legs. Based on this research, we can conclude that employees hand hygiene behavior may be subconsciously influenced by cues in the environment. Furthermore, an increased number of employees in the nursing home would contribute to this, as the staff would have more time for residents. Finally, in preventing the HCAI, motivation, clearly defined goals, high professional qualifications, and teamwork of all em- ployees in the nursing home ward are also important. REFEREnCES [1] Long-Term Care for the elderly. Provisions and providers in 33 European countries Luxembourg: Publications Office of the European Union, 2012: http://ec.europa.eu/justice/gender-equality/files/elderly_care_en. pdf (14. 11. 2017). [2] Lejko Zupanc T, Logar M, Mrvič T, eds . Učne delavnice o bolnišničnih okužbah v domovih za starejše občane. Ljubljana: Služba za preprečevanje in obvladovanje bolnišničnih okužb, UKC Ljubljana, 2011: 7–68. [3] Šprajcar D. Standardi pomoč pri zagotavljanju kakovostne in varne zdravstvene oskrbe. In: Grmšek Košnik I, Hvalič Touzery S, Skela-Savič B, eds. Okužbe povezane z zdravstvom, zbornih prispevkov z recenzijo. 4. 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JevšnikUse of a nudge tool for improving hand hygiene in a nursing team in home for elderly people – case study Based on this research, we can conclude that employees hand hygiene behavior may be subconsciously influenced by cues in the environment. © Inštitut za sanitarno inženirstvo, 201746  [8] Birnbach DJ, King D, Vlaev I et al. Impact of environmental olfactory cues on hand hygiene behaviour in a simulated hospital environment: a randomized study. J Hosp Infect. 2013; 85(1): 79– 81. doi: 10.1016/j. jhin.2013.06.008. [9] Gold A, Lichtenberg P. Don't call me ''nudge'': the ethical obligation to use effective interventions to promote public health. Am J Bioeth. 2012; 12(2): 18–20. doi: 10.1080/15265161.2011.634486. [10] Lehrer R. Moving through hospitals: designing handwashing. Core JR. 2012: http://www.core77.com/posts/22185/designing-handwashing-part- 2-diverse-nudges-in-a-hospital-22185 (20. 10. 2016). [11] Schuld-Jensen J, Moesgaard F, Arestrup SC. 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Nurs Times. 2016; https://www.nursingtimes.net/news/hospital/visual-triggers-increase- hand-hygiene-compliance/7005465.article (13. 11. 2016). [17] Ford EW, Boyer BT, Menachemi N et al. Increasing hand washing compliance with a simple visual cue. Am J Public Health. 2014; 104(10): 1851–6. doi: 10.2105/AJPH.2013.301477. [18] Nevo I, Fitzpatrick M, Thomas RE et al. The efficacy of visual cues to improve hand hygiene compliance. Simul Healthc. 2010; 5(6): 325–31. doi: 10.1097/SIH.0b013e3181f69482. [19] Železnik D, Ivanuša A, Železnik P et al. Standardi aktivnosti zdravstvene nege. Maribor: Fakulteta za zdravstvene vede, 2008: 105–15. [20] Delovna skupina pri ministrstvu za zdravje RS. Strokovne podlage in smernice za obvladovanje in preprečevanje okužb, ki so povezane z zdravstvom oziroma zdravstveno oskrbo. 2 dopolnjena izdaja. 2009: http://www.mz.gov.si/si/delovna_podrocja_in_prioritete/zdravstveno_ varstvo/kakovost_in_varnost/nacionalna_komisija_za_obvladovanje_ bolnisnicnih_okuzb/strokovnjaki/ (20. 11. 2016). [21] Kazalniki kakovosti v zdravstvu, 2010: http://www.mz.gov.si/si/delovna_ podrocja_in_prioritete/zdravstveno_varstvo/kakovost_in_varnost / kazalniki_kakovosti/ (28. 2. 2017). [22] Kotnik-Kevorkijan B. Epidemiološo spremljanje bolnišničnih okužb v Sloveniji in rezultat raziskav. In: Grmšek Košnik I, Hvalič Touzery S, Skela Savič B, eds. Okužbe povezane z zdravstvom, zbornih prispevkov z recenzijo. 4. simpozij Katedre za temeljne vede, Kranj, 15. oktober 2013. Jesenice: Visoka šola za zdravstveno nego, 2013: 32–40. [23] Ahmed-Lecheheb D, Cunat L, Hartemann P et al. Prospective observational study to assess hand skin condition after application of alcohol-based hand rub solution. Am J Infect Control. 2012; 40(2):160– 4. doi: 10.1016/j.ajic.2011.04.323 [24] Vallgarda S. Nudge – a new better way to improve health. Health Policy. 2016; 104(2): 200–3. doi: 10.1016/j.healthpol.2011.10.013. [25] Nudging your way to success. TED Radio hour. NPR 24 hour program stream, 2008: http://www.npr.org/templates/story/story.php?storyId= 89530290 (12. 10. 2016). T. Mlakar, A. Mihelič Zajec, M. Jevšnik Use of a nudge tool for improving hand hygiene in a nursing team in home for elderly people – case study © Inštitut za sanitarno inženirstvo, 2017 International Journal of sanitary engineering researchVol. 11  No. 1/2017 S it r Engineering Research 47 Impact of boiling on raw milk – food safety aspects Daniel MAEStRo1,2*, Arzija PAŠAlIĆ1,2, Fatima JUSUPoVIĆ3, Enisa šlJIvo4 ABStRACt goal: Milk is a nutrient of high biological value, consumed in larger quantities and frequencies by sensitive groups of population. This fact makes the monitoring of milk’s safety particularly important for the public health. An increasing number of persons consume raw, unpasteurized milk. Superior nutritional value, quality, taste and other health benefits are advocated as reasons for increased interest in the consumption of the raw milk. However, scientifically based data to support such claims are very limited. Almost all of the international advisory and regulatory agencies dealing with food safety strongly support the principle of exclusive consumption of pasteurized milk. This research seeks to verify both the positive and negative impacts of boiling on the safety of the raw milk. Scope: This study was conducted on 30 samples of raw milk, selected by a method of random sampling from individual retailers in grocery stores and open markets in the city of Sarajevo. The boiling process was conducted by heating the raw milk to its boiling point during 20 seconds. Each collected sample was divided into two groups (A and B), where sample A was analysed before, and sample B after the boiling process. Findings: The study determined that the boiling process improves the safety of raw milk, and is responsible for an exceptional and significant increase of its microbiological safety. The study also revealed that the safety of raw milk in the Sarajevo Canton derogates from provisions in force for the raw milk. key words: raw milk, boiling, safety 1 Institute for Public Health of the Federation of Bosnia and Herzegovina, Maršala Tita 9, Sarajevo, Bosnia and Herzegovina 2 Association for Sanitary Engineering in Bosnia and Herzegovina, Augusta Brauna 10, Sarajevo, Bosnia and Herzegovina 3 Faculty of Health Studies of the University of Sarajevo, Bolnička 25, Sarajevo, Bosnia and Herzegovina 4 Tobacco Factory Sarajevo, Bosnia and Herzegovina * Corresponding author Daniel Maestro, Institute for Public Health of the Federation of Bosnia and Herzegovina, Maršala Tita 9, Sarajevo, Bosnia and Herzegovina E-mail: d.maestro@zzjzfbih.ba Received: 22. 12. 2017 Accepted: 27. 12. 2017 Original scientific article  © Inštitut za sanitarno inženirstvo, 201748  IntRoDuCtIon Human interest in the consumption of safe food exists from ancient times, which resulted with global demand for production of food that could be used without risks upon health of humans. In addition to the macro and micro nutrients, as well as the non-nutritive natural compo- nents of food, often responsible for its organoleptic properties, biologi- cal values and admission, the food also contains numerous other sub- stances being more or less harmful to human health. These, primarily, concern the microorganisms and their toxins, additives and residues of contamination. Examination of food’s safety rests on evidencing the presence of such substances and their determination [1]. Food safety implies that a food will not cause adverse effects on human health if prepared and consumed in accordance with its intended use [2]. From the perspective of a healthy and balanced diet, milk is a unique food in many different ways. It is of natural origin, and contains all the ingredi- ents needed for proper nutrition of an organism, either of a child or an adult [3]. Milk is a food of high biological value used in larger quantities and fre- quencies by sensitive population groups (children, pregnant women, elderly persons). This fact makes the monitoring of milk’s safety particu- larly important for public health [4]. Specific regulations on microbio- logical safety of food had set the norms for each food with respect to the type and number of microorganisms allowed for nutrition of humans [1]. Access of individual elements into the food chain can differ, yet pre- dominantly depends on activities of humans. Contamination of food and environment with inorganic pollutants may be of primary or of secondary character. Primary contamination implies that the contami- nation of the plant foods was conducted through soil, water or air, whereas the contamination of animals was conducted through food or water. Secondary contamination implies that the contamination of food occurred during its processing, packaging or storage due to the migration of toxic metals from equipment, packaging, appliances, utensils or contaminated food additives. Quality of milk depends of its composition and level of hygiene applied during the milking process, i.e. the purity of milking pots, condition of its storage place, mode of transport and cleanliness of each animal’s udders. Production of milk and dairy products under non-hygienic conditions and poor manufac- turing practices may cause setbacks for both the public health and the economy [4]. Raw milk can be contaminated by a wide range of bacteria, including Staphylococcus aureus, Escherichia coli, Bacillus spp., Brucella spp., Listeria monocytogenes, Salmonella spp. and Corynebacterium spp., as well as by a number of moulds and yeasts [5]. In some cases, the milk’s infection with viable pathogenic bacteria may cause its contami- nation and spoilage, which makes the milk unsafe. Main life threatening diseases associated with milk include gastroenteritis, diarrhea, typhoid or tuberculosis of the cattle [6]. D. Maestro, A. Pašalić, F. Jusupović et al. Impact of boiling on raw milk – food safety aspects Milk is a food of high biological value used in larger quantities and frequencies by sensitive population groups (children, pregnant women, elderly persons). Production of milk and dairy products under non-hygienic conditions and poor manufacturing practices may cause setbacks for both the public health and the economy. International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 49  The toxic metabolites of aflatoxin may also be found in animal products, milk and meat, in case the cattle feed was previously contaminated with moulds [7]. Aflatoxin M1 is a relatively stable molecule, which cannot be inactivated by the heating treatments like pasteurization and sterilization [8]. Due to these characteristics, Aflatoxin M1 may have adverse effects on health of humans, particularly of children who are the main consumers of milk and dairy products [9]. MAtERIAlS AnD MEtHoDS Our analysis was conducted on 30 samples of raw milk, selected by a method of random sampling from individual retailers in grocery stores and open markets in the city of Sarajevo. Criteria for sampling was that the raw milk in question can be found in official grocery stores or at open markets of the Sarajevo Canton. The samples were collected in sterile laboratory containers and kept stored in refrigerating showcases on temperature varying from 4 to 8 oC. The samples were transported on temperature of 4 oC, and, pending the analysis, kept in storage on temperature of -20 oC. Collected samples were labelled in accordance with the standard labo- ratory procedures for receipt and labelling of samples. Each collected sample was split into two groups (A and B), where sample A was ana- lysed before, and sample B after the boiling process. The boiling was conducted by heating the raw milk to the point of its boiling, it most frequently being between 97-102,5 °C, which depended of the milk’s composition. Once the boiling point was reached, the milk was heated for additional 20 seconds, by which the boiling treatment was complet- ed [10]. Determination of heavy metals (lead, Arsenic) Analysis of samples (that were firstly prepared in a microwave oven) on the presence of heavy metals (lead, arsenic) was conducted in the SHI- MADZU AA-6650 atomic absorption spectrophotometer. Even though the SHIMADZU AA – 6650 atomic absorption spectrophotometer is mainly used for determination of concentration of heavy metals in a sample, it may also be used for some other tasks to depend of the soft- ware and the needs. The principle of its work is based on atomic ab- sorption and spectrophotometry. The SHIMADZU AA-6650 atomic ab- sorption spectrophotometer combines two correction functions, the D2 method (deuterium lamp method) and the SR method (self-reversal method), thus enabling that the samples are examined under appropri- ate method. Determination of Aflatoksin M1 Quantitative analysis of Aflatoxin M1 in the milk samples was conduct- ed through application of the ELISA testing (Enzyme-linked Immuno- sorbent Assay). The principle was to test the antigen – antibody reac- tion. The test kit contained reagents for 96 samples (including the calibration curves). Samples of the milk were initially defatted by cen- D. Maestro, A. Pašalić, F. Jusupović et al.Impact of boiling on raw milk – food safety aspects Aflatoxin M1 may have adverse effects on health of humans, particularly of children who are the main consumers of milk and dairy products. © Inštitut za sanitarno inženirstvo, 201750  trifugation of cold milk in conical tubes at 2000 x g of rotation for 10 minutes. The layer of fat created on the top has been removed with a spatula, and 100 μL of the defatted milk was used for the ELSA testing. The standards were concentrated and needed a dilution with standard diluents prior to the testing. The calibration curve illustrates the ratio of concentration of Aflatoxin M1 in the standard and the value of its ab- sorption at 450 nm, displayed on the reader of the microtiter plate “DAS PLATE READER”. All of the milk samples were prepared in ac- cordance with the instructions contained in the ELISA kit. Microbiological parameters For evidencing, we used the following microbiological methods: the Horizontal method for detection of Salmonella spp (BAS EN ISO 6579:2005); the Horizontal method for detection and counting of co- agulase-positive staphylococci – Staphylococcus aureus (BAS EN ISO 6888-1:2005); the Horizontal method for detection and counting of Enterobacteriaceae (BAS EN ISO 21528-2:2008); the Horizontal method for counting of Clostridium perfringens – the colony counting method (BAS EN ISO 7937:2005); the Horizontal method for count- ing of microorganisms – technique of counting the colonies at 30 de- grees Celsius (BAS EN ISO 4833:2006); the Horizontal method for detection and counting of Listeria monocytogenes (BAS EN ISO 11290-1:2005). Statistical data processing The results of the analysis have been statistically processed through ap- plicable and verified methods – the Microsoft Excel 2010 computer program and the IBM® SPSS® Statistics 24.0 software. By applying appropriate functions available within the IBM® SPSS® Statistics 24.0 software, there have been calculated the basic statisti- cal parameters of: the mean (MEAN) and variability measures – stand- ard deviation (SD) and standard error of the mean (SEM). To acquire a more detailed interpretation and a better understanding of the obtained results, we have also used the Microsoft Excel 2010 computer program to calculate percentages of the average values of certain parameters af- ter the boiling of examined milk samples. The statistical significance of differences between the measured values of the examined parameters in the raw and boiled milk was evaluated by a dependant (paired) two-tailed t testing, and calculated in the IBM® SPSS® Statistics 24.0 software. RESultS AnD DISCuSSIon Out of 30 samples of the raw cow’s milk that were tested, 16 samples (53.3%) proved unsafe. Following the method of boiling that was used, 7 samples (23.3%) remained unsafe. D. Maestro, A. Pašalić, F. Jusupović et al. Impact of boiling on raw milk – food safety aspects International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 51  Results of microbiological parameters Average number of colonies of aerobic mesophilic bacteria in the sam- ples of raw milk was 8.1×102, while the samples of boiled milk showed the value of 1×101. The average number of colonies of aerobic mes- ophilic bacteria in boiled milk decreased by 99.33% in comparison to the average number of same bacteria in the raw milk, and t-test (t=7.93) showed statistically significant difference (t=7.93; p <0.0001). The average number of colonies of Staphylococcus aureus in the raw milk samples was 1.7×102. Presence of such bacteria was not noted in any sample of the boiled milk, and the t-test showed statistically signifi- cant difference (t = 4.79; p <0.0001). The average number of colonies of Enterobacteriaceae bacteria in the samples of raw milk was 1.6×102, while their presence in the samples of boiled milk was not found at all. Application of the t-test demonstrated a statistically significant differ- ence (t = 5.22; p <0.0001). Neither of the samples of raw milk dem- onstrated the presence of Salmonella spp., Clostridium perfringens or Listeria monocytogenes. table 1: Display of safe and unsafe samples of milk, before and after boiling type of sample Safe unsafe Raw milk 14 (46,6%) 16 (53,3%) Boiled milk 23 (76,6%) 7 (23,3) table 2: Comparative review of the number of aerobic mesophilic bacteria (CFU/g), Staphylococcus aureus (CFU/g) bacteria and enterobacteriaceae (CFU/g) in samples of raw and boiled milk Sample Aerobic mesophilic bacteria (CFu/g) Staphylococcus aureus (CFu/g) Enterobacteriaceae (CFu/g) Raw milk Boiled milk Raw milk Boiled milk Raw milk Boiled milk Mean 8,1×102 1×101 1,7×102 0 1,6×102 0 SD 5,4×102 5 1,9×102 0 1,7×102 0 Min 6,4×101 0 1,2×101 0 5,2×101 0 Max 1,8×103 2x101 8,8×102 0 6,2×102 0 p-value < 0,0001* < 0,0001* < 0,0001* * t-test Results of the heavy metals testing (As, Pb) Average level of arsenic in raw milk samples was 0.01 mg/l, while no evidence of presence of this heavy metal was noted in any sample of the boiled milk. The t-test showed a statistically significant difference (t = 3.42; p = 0.001). The average level of lead in raw milk samples was 0.03 mg/l, and in the boiled milk samples 0.01 mg/l, thus showing a decrease in the av- erage level of lead in tested samples of the letter category by 73.34%. Application of the t-test demonstrated a statistically significant differ- ence between the samples of raw and boiled milk (t = 3.42, p = 0.02). D. Maestro, A. Pašalić, F. Jusupović et al.Impact of boiling on raw milk – food safety aspects © Inštitut za sanitarno inženirstvo, 201752  table 3: Comparative review of arsenic (As) and lead (Pb) levels in samples of raw and boiled milk Sample level of As (mg/l) level of Pb (mg/l) Raw milk Boiled milk Raw milk Boiled milk Mean 0,01 0,00 0,03 0,01 SD 0,016 0,000 0,057 0,017 Min. 0,000 0,000 0,000 0,000 Max. 0,072 0,000 0,222 0,064 p-value 0,0019* 0,0214* *t-test Results of the study relating to presence of Aflatoxin M1 Due to low level of detected concentrations of Aflatoxin M1, the results were displayed in pg/ml instead of μg/l, as required by the Rulebook on maximum permitted levels of certain contaminants in foodstuffs (“The Official Gazette of Bosnia and Herzegovina”, No. 37/09). No significant difference in concentration of Aflatoxin M1 was detected between the samples of raw and boiled milk. The average concentration of Aflatoxin M1 in samples of raw milk was 0.68 pg/ml, and in the samples of boiled milk 0.675 pg/ml. The statistical significance of this difference was additionally evaluated by t-testing, when no statistically significant difference was found (p> 0.05). Figure 1: Comparative review of measured levels of Arsenic (mg/l) in raw and boiled milk Figure 2: Comparative review of measured levels of Lead (mg/l) in raw and boiled milk D. Maestro, A. Pašalić, F. Jusupović et al. Impact of boiling on raw milk – food safety aspects International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 53  The results of the analysis on the raw milk’s safety clearly indicate that the raw milk available in the Canton of Sarajevo derogates from applica- ble regulations on the raw milk. By boiling such milk, its safety improves. The results of the comparative microbiological analysis of samples of raw and boiled milk clearly show a very pronounced influence of the ap- plication of this treatment towards the increase of microbiological stabil- ity of the milk by reducing the microbiological contamination of the raw milk. The pronounced decrease in the number of aerobic mesophilic bacteria, as well as the complete destruction of enterobacteriaceae and staphylococci is in line with expected results resting on the data from professional literature, which finds the boiling method a very effective mean of prevention of possible risks for poisoning the raw milk by bac- teria [11]. Staphylococcus aureus was found in all of the examined sam- ples of raw milk, where 50% of the tested samples showed the value of > 102, it being higher than evidenced in a research conducted in the Czech Republic [12]. The data clearly indicate that pore hygiene condi- tions were applied during the milking, packing and transport of raw milk; as such, the contamination of raw milk is of secondary character. The results of the quantitative analysis of Aflatoxin M1 show that the boil- ing of milk does not affect the presence of this mycotoxin. These results are consistent with the literature on the thermostability of its molecule, which cannot be destroyed in the process of pasteurization and steriliza- tion [8]. The obtained results indicate that the boiling does reduce the concentration of lead and arsenic, as unstable metals that could be lost with this treatment. In addition to being non-thermostable at high temper- atures, these metals also tend to bind to proteins [13], so their reduced concentration in the boiled milk can also be explained by the fact that they could have been previously removed as tied to coagulated proteins in the surface layer of removed fat. However, the measured concentrations of these metals in raw milk are very low (much lower than their maximum allowed amounts), so no final conclusions can be drawn as to the effect of boiling of milk on its health safety in terms of concentration of these heavy metals. In subsequent researches, this problem could be solved through an experiment in which the raw milks would be contaminated with certi- fied reference materials of Pb and As, and then boiled. The concentrations Figure 3: Comparative review of measured concentrations of Aflatoxin M1 (pg/ml) in raw and boiled milk D. Maestro, A. Pašalić, F. Jusupović et al.Impact of boiling on raw milk – food safety aspects The results of the quantitative analysis of Aflatoxin M1 show that the boiling of milk does not affect the presence of this mycotoxin. © Inštitut za sanitarno inženirstvo, 201754  of the mentioned metals would be measured after the boiling of contami- nated milk by the method that was described and applied in this paper. ConCluSIon Boiling of raw milk improves its safety and has a very pronounced and significant influence on increase of its microbiological safety. In other words, it is a very effective method for destroying all present pathogens in the raw milk. With respect to chemical contaminants, the boiling of milk proved to be effective in reducing the concentration of arsenic, though not lead. The boiling of milk has no effect on the reduction of concentration of Aflatoxin M1. The safety of raw milk in the Canton of Sarajevo derogates from regulations in force for the raw milk. The re- sults of this work clearly point to the need for educating and informing the population consuming the raw milk in terms of changing their habits as well as removing prejudices related to the boiling of milk. REFEREnCES [1] Mirić M., Šobajić S. (2002): Safety of foodstuffs, Belgrade, 18, 19–20, 23, 122, 124. [2] Law on Food (“The Official Gazette of Bosnia and Herzegovina” No. 50/04). [3] Pickeling L., Baker C.J., Kimberling D.W., Long S. (2012): Prevention of disease from potentially contaminated food product, American Academy of Paediatrics, 917–918. [4] Božanić R. (2000): Impact of type and composition of milk on the intestinal bacteria of lactic acid and the quality of fermented beverages (dissertation). Zagreb: Faculty of Food Technology and Biotechnology. [5] Swai E.S., Schoonman L. (2011): Microbial quality and associated health risks of raw milk marketed in the Tanga region of Tanzania. Asian Pac Trop Biomed 1: 217–222. [6] Al-Khatib I.A., Al-Mitwalli S.M. (2009): Microbiological quality and sample collection policy for dairy products in Ramallah and Al-Bireh districts, Palestine. EastMediterr Health J 15: 709–716. [7] Naglić T., Hajsig D., Madić J., Pinter LJ. (2005): Veterinary microbiology – Special bacteriology and mycology: Mycotoxicosis, Faculty of Veterinary Medicine in Zagreb, Zagreb, Croatian Microbiological Society. [8] Cvaliere C., Foglia E., Pastorini R., Samperi P., Lagana A. (2006): Liquid chromatography/tandem mass spectrometric confirmatory method for determining aflatoxin M1 in cow milk – Comparison between electrospray and atmospheric pressure photoionization sources. J. Chromatogr. A 1101, 69–78. [9] Regulation on the quality of raw milk and the manners for determining the price of raw milk, (“The BiH Official Gazette”, No. 70/08). [10] Croatian Food Agency (2012): General instruction on hygienic production of food, Guidelines for persons dealing with food, Osijek, Republic of Croatia. [11] Govaris A., Roussi V., Koidis P.A., Botsogloub N.A. (2002): Distribution and stability of aflatoxin M1 during production and storage of yoghurt. Food Additives & Contaminants 19 (11): 1043-1050. [12] Bogdanovičová K., Marcela Vyletělová-Klimešová M., Babák V., Kalhot L., Koláč Kovačkova K., Renáta Karpíškova R. Microbiological Quality of Raw Milk in the Czech Republic. Czech J. Food Sci., 34, 2016 (3): 189–196. [13] Kirberger M., Wong H.C., Jiang J., yang J.J. (2013): Metal toxicity and opportunistic binding of Pb(2+) in proteins. J Inorg Biochem. 125:40–9. D. Maestro, A. Pašalić, F. Jusupović et al. Impact of boiling on raw milk – food safety aspects The boiling of milk has no effect on the reduction of concentration of Aflatoxin M1. © Inštitut za sanitarno inženirstvo, 2017 International Journal of sanitary engineering researchVol. 11  No. 1/2017 S it r Engineering Research 55 A comparison of three different cleaning methods for reducing contaminants on contact surfaces – a preliminary study 1 University of Ljubljana, Faculty of Health Sciences, Zdravstvena pot 5, Ljubljana, Slovenia * Corresponding author Mojca Jevšnik, University of Ljubljana, Faculty of Health Sciences, Zdravstvena pot 5, Ljubljana, Slovenia E-mail: mojca.jevsnik@zf.uni-lj.si Mojca JEvšnIk1*, Andrej ovCA1, Peter RASPoR1 ABStRACt The aim of this study was to evaluate three different cleaning procedures routinely applied in processes to prevent microbiological product contamination. The evaluation was done in the context of their hygienic suitability and cleaning effectiveness according to defined surface hygiene standards. Furthermore, the suitability of a generic testing method to monitor cleaning effectiveness was investigated. The results of this preliminary study revealed discrepancies between the results acquired with a generic method compared to the conventional microbiological surface examination in the context of surface hygiene monitoring. The results demonstrate the higher efficiency of the semi-automatic system in comparison to the mechanical system on surfaces with the same characteristics. The results also indicate that in both of applied the semi-automatic systems, cleaning effectiveness depends on the surface accessibility and cleaning direction. Based on the results presented, we can conclude that for maximum benefit, visual, non-microbiological, and microbiological methods should be combined as an integrated cleaning monitoring strategy. key words: cleaning, two-bucket system, box system, mechanical cleaning, visual inspection, microbiological control, hygiene Received: 12. 12. 2017 Accepted: 18. 12. 2017 Original scientific article  © Inštitut za sanitarno inženirstvo, 201756  IntRoDuCtIon The environment of the processes with high hygiene control to prevent product contamination is an important factor in determining the quali- ty and safety of the final products. Sandle [1] noted that cleaning and disinfection are necessary in order to prevent microorganisms surviv- ing in cleanrooms and for maintaining a level of hygiene in laborato- ries. Cleaning is needed to remove soil (such as protein and grease) from surfaces, and disinfection, if necessary, to inactivate or to kill microorganisms. As Moore and Griffith [2] stated, ‘cleanliness’ is, however, a relative concept: what is acceptable as being ‘clean’ in one situation may be unacceptable in another. Lelièvre et al. [3] asserted that cleaning is a complex phenomenon whose efficiency depends on production conditions and the design of equipment, and on operating conditions. Indeed, soils generated during production are often com- plex, containing microorganisms as well as organic material, which could modify both the microorganisms and the solid surface proper- ties [3]. Prabu et al. [4] pointed out that pharmaceutical products and active pharmaceutical ingredients (APIs) can be contaminated by oth- er pharmaceutical products or APIs by cleaning agents, by microor- ganisms, or by other materials (e.g., airborne particles, dust, lubri- cants, raw materials, intermediates, and auxiliaries). Adequate cleaning procedures are essential in order to avoid product contamina- tion especially microbiological contamination. Documented standard cleaning procedures for each piece of equipment should be prepared for a comprehensive infection prevention strategy and an important step in the manufacture of pharmaceutical products [5, 6]. It is vital that the equipment design is evaluated in detail in conjunction with the product residues that are to be removed, the available cleaning agents and cleaning techniques when determining the optimum clean- ing procedure for the equipment. Cleaning procedures should be suffi- ciently detailed to remove the possibility of any inconsistencies during the cleaning process. The following parameters are to be considered during cleaning procedures [5]. Shi and Zhu (2009) indicated that bi- ofilms were often established by various microorganisms on the equip- ment surfaces of the production line. L. monocytogenes became one of the major causes of contamination of food products or transmission of diseases. Therefore, it is very important to develop cleaning and disin- fection methods and control systems in food-processing plants and en- vironments. Prabu et al. [4] indicated that cleaning has recently at- tained a position of increasing importance in the pharmaceutical indus- try. Virtually every aspect of manufacturing involves cleaning, from the initial stages of bulk production to the final dosage form to ensure the safety, identity, strength, quality, or purity of the drug product. Modern pharmaceutical manufacturing involves highly technically trained per- sonnel, complex equipment, sophisticated facilities, and complex proc- esses. Akl et al. [7] indicated that the cleaning procedures for the equipment must be validated according to good manufacturing practice (GMP) rules and guidelines. Cleaning validation is, however, a signifi- cant analytical challenge for the pharmaceutical industry [8]. The pur- M. Jevšnik, A. Ovca, P. Raspor A comparison of three different cleaning methods for reducing contaminants on contact surfaces... Cleaning and disinfection are necessary in order to prevent microorganisms surviving in cleanrooms and for maintaining a level of hygiene in laboratories. International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 57  pose of cleaning validation is to prevent contamination and cross-con- tamination in pharmaceutical dosage forms [4]. Cleaning validation is a documented process that proves the effectiveness and consistency of cleaning pharmaceutical production equipment. Cleaning validation consists of two separate activities: the first is the development and vali- dation of the cleaning procedure used to remove drug residues from manufacturing surfaces and the second involves the development and validation of methods for quantifying residuals from the surfaces of manufacturing equipment. Furthermore, many sampling points of the manufacturing facility and the manufacturing equipment have to be tested to verify the occurrence of contamination [7]. Peles et al. [9] stated that the typical residual acceptance limits (RAL) used to verify the cleanliness of pharmaceutical manufacturing equipment are select- ed for residuals that are deemed to be a risk to subsequent products based on potency and toxicity. The limits are defined as residual mass/ surface area (μg/cm2) and fall well below the accepted “visibly clean” limit of 100 μg per 25 cm2 [10, 11]. The residual mass on the manu- facturing equipment surface is quantified with a validated analytical methodology from swab extracts or rinse, the products of swab or rinse sampling [9]. Griffith et al. [12] demonstrated that the effectiveness of sanitation pro- cedures has traditionally been evaluated using different methods, such as visual inspection, swabs, dipslides and contact plates. Visual inspec- tion is insufficient for defining cleanliness [13] or for objectively evaluat- ing the microbial contamination of all surfaces [14], although this meth- od is still widely used to assess the level of cleanliness [15]. ATP bioluminescence is a widely used technique for the rapid validation about cleaning effectiveness. Compared with traditional microbiological testing, ATP bioluminescence has advantages including the rapidity of its results, which can be obtained within 2 min [15]. Among the rapid tests, Oberyszyn and Robertson [15] developed a method to examine aerosol containment using a modified, commer- cially available product called Glo Germ® (Glo Germ, Moab, UT). This product is used for teaching aseptic techniques in hospitals, industry, restaurants, and schools and is visualized with ultraviolet (UV) or black light. Glo Germ® is available in three forms: a white powder, an orange oil-based suspension, and a white lotion based suspension of a melamine copolymer resin. Carrascosa et al. [16] summarised the re- sults of some studies, which considered rapid techniques to be par- ticularly useful in large manufacturing plants where regular and fre- quent monitoring can provide management with data on trends. In the case of ATP, it also provides rapid results of the amount of organic re- mains and microbial contamination on the surfaces of establishments. Calvert et al. [17] pointed out that this method does not identify the quantity of the microorganisms or contaminant species; it can be used as a medium for monitoring hygiene and verifying cleanliness. Conse- quently, to monitor the efficacy of disinfection procedures, some microbiological testing (using dip slides, contact plates, or swabs) may be required [16]. M. Jevšnik, A. Ovca, P. RasporA comparison of three different cleaning methods for reducing contaminants on contact surfaces... Compared with traditional microbiological testing, ATP bioluminescence has advantages including the rapidity of its results, which can be obtained within 2 min. © Inštitut za sanitarno inženirstvo, 201758  The aim of this study is to analyse three different cleaning procedures, applying their specific protocols (the double bucket system, the box sys- tem, and the mechanical cleaning) in order to determine the differences between them and to examine their hygienically suitability when used in processes of high hygiene control. To perform this study holistically, we also included cleaning verification with a generic test. MAtERIAlS AnD MEtHoDS Surface cleaning techniques The three different cleaning techniques described in Table 1 were evalu- ated. table 1: Description of cleaning techniques Cleaning type Cleaning procedure Box system The box system provides prepared cleaning wipes impregnated with 1% cleaning solution* ready to use and stored in a box fixed on the handcart. The excess cleaning solution is strained off and stored in the separate compartment under the box. Wipes are used via the telescoping stick and changed after approximately every 2 m2 or more often if cleaning effectiveness is not sufficient. There is no wring-out step. Used wipes are collected in a separate compartment also fixed on the handcart. Double bucket system Two buckets fixed in the handcart are filled with 1% cleaning solution*. The first (blue) bucket contains 15L and the second (red) bucket contains 2L of prepared cleaning solutions. A cleaning wipes wringer is located above the red bucket. The wipe is first soaked in the red bucket, wring out and used for cleaning. After that, approximately every 2m2 the wipe is soaked again into the red bucket, rinsed and wrung out, followed by soaking it in the blue bucket and wringing it out. After the cleaning procedure in one room is finished, the cleaning solution in both buckets is replaced with a new one. Mechanical cleaning The cleaning machine is composed of a reservoir for clean water (filled in before the cleaning procedure) and the dosage compartment containing a 1% cleaning solution*. The cleaning procedure is executed with the round horizontal wheel in the bottom of the cleaning machine. After the cleaning procedure is finished, the wastewater is removed from the reservoir, followed by rinsing and drying the equipment. Also, the cleaning wheel coming into contact with the surface is rinsed under running water and dried. legend: *Alcohol-based cleaner suitable for use on all water-resistant surfaces, objects, and floor coverings as well as on coated floors. Ingredients according to 648/2004/EC [18] Non-ionic surfactants < 5%, water-soluble solvents, fragrances (linalool), preservatives (methyl-/methylchloroisothiazolinone). pH value (concentrate): approx. 7 pH value (ready-to-use solution): approx. 7.5 The box and double bucket system were evaluated in two separate but comparable areas. Mechanical cleaning was evaluated in the area typi- cal for that type cleaning. The surface material evaluated was the same in all three areas. Sampling points Sampling points (20 cm2 each) were systematically selected regardless of the area and cleaning type investigated (Table 2). When selecting the sampling points, accessibility and workload in the area as criteria were considered. Sampling points 1 to 6 were equally distant from each other (50 cm) and, in the case of sampling points 1 to 4, equally distant from the walls and corners (15 cm). To assure that a sampling point was al- ways on the same spot, the centre of the sampling point was marked with a small black dot resistant to the cleaning procedures evaluated. M. Jevšnik, A. Ovca, P. Raspor A comparison of three different cleaning methods for reducing contaminants on contact surfaces... International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 59  Surface visual control with glo germ® On each sampling point from 1 to 6 (Table 2), different kits (lotion- based, oil-based, and powder) were deposited before the cleaning pro- cedure. Each kit was first deposited on the sampling point in the size of a pea and then distributed with a cotton swab on a surface of 20 cm2. There was no cleaning of the surface for at least 20 minutes after depo- sition. After the cleaning procedure had been completed, each sampling point was checked in detail under the UV light. If there were no kit re- sidual left on the surface, the sampling point was evaluated with a mark of 1 during evaluation. If there were any remains left on the surface the sampling point was evaluated with a mark of 0. Surface sampling and microbiological analysis Systematic unannounced surface sampling was executed in three se- quences in the case of each type of cleaning. During each sequence, two sampling intervals were done. Before the first surface sample (BC) was taken, the surface cleaning was not done for at least 24 h. The second sample (AC) was taken 25 minutes after the cleaning procedure to assure that the sampling point was completely dry. To exclude clean- ing accessories as a possible cause of contamination cleaning solutions and wipes were also sampled before the cleaning procedure and ana- lysed in each sampling sequence. Surface samples and samples from cleaning wipes (Box and double bucket system) were taken with sterile swabs (cotton swab in 9 mL sterile physiological solution). The surface sampling technique was ap- plied according to the ISO18593 standard [19]. The cleaning solution was collected in sterile 100 mL containers prior to the cleaning proce- dure starting. Microbiological analysis was performed in an internal microbiological laboratory of a company with processes of high hygiene control. Ac- cording to the internal company standards of environmental microbio- logical quality, Gram+ bacteria were determined. Surface samples were incubated on Soybean Casein Digest Agar Medium for 5 days at 30 ± 2 °C. Before incubation on agar media, samples of cleaning solutions were treated with aseptic membrane filtration (0,46 μ) in a laminar flow cabin. Because internally determined warning and action limits for Gram+ bacteria were not exceeded in AC samples, no further specific table 2: Description of sampling points Sampling point Sampling point criteria 1 Right corner area close to the room entrance. 2 Right corner area opposite to the room entrance. 3 Left corner area opposite the room entrance. 4 Left corner area close to the room entrance. 5 Area in the middle of the room opposite to the room entrance. 6 Area in the middle of the room close to the room entrance. M. Jevšnik, A. Ovca, P. RasporA comparison of three different cleaning methods for reducing contaminants on contact surfaces... Surface samples and samples from cleaning wipes were taken with sterile swabs. Microbiological analysis was performed in an internal microbiological laboratory of a company with processes of high hygiene control. © Inštitut za sanitarno inženirstvo, 201760  analysis were done. Standards of environmental microbiological quality (warning limit and action limit) are internal in their nature and therefore not published in this paper. RESultS Simple visual inspection of the sampling points after cleaning was in all cases evaluated as visually clean because there were no kit residues on the surfaces that would be visible to the naked eye. However, based on the results presented in Table 3, we can determine that based on the GloGerm® method there are differences visible under UV light. The re- sults in Table 3 demonstrate that the most effective way of cleaning is mechanical cleaning, which successfully removed all three kit types from the surface in all sampling points except 1st and 6th. Monitoring of cleaning effectiveness after applying the system and the two-bucket system has revealed that the test kit applied on the surface was often smudged (especially when sampling points are more difficult to reach) and, therefore, evaluated as not being sufficiently clean. Comparison of the box system and the two-bucket system also reveals that the oil- based kit is more successfully removed from the surface with the box system, while efficiency in case of other two kits applied is comparable and related more to the sampling point. We can see that situation at sampling point 1 and 6 is generally, at least, satisfying (Table 3). table 3: Evaluation of surface cleanliness after cleaning according to cleaning type and the sampling point using Glo Germ® method Cleaning type kit type Sampling point 1 2 3 4 5 6 Box system Lotion-based 0 1 1 0 1 0 Oil-based 1 1 1 1 1 1 Powder 0 1 0 0 1 0 Double bucket system Lotion-based 0 1 1 1 1 0 Oil-based 0 1 0 0 0 0 Powder 1 0 1 1 0 0 Mechanical cleaning Lotion-based 0 1 1 1 1 0 Oil-based 0 1 1 1 1 0 Powder 0 1 1 1 1 1 Legend: 1 – Complete absence of the kit under UV light; 0 – remains of the kit visible under UV light A microbiological investigation was also conducted. In most of the cas- es presented in Table 4, the number of CFU is already low before clean- ing. The internally defined surface hygiene standard defined as action limit of 200 CFU is not crossed, indicating good hygiene practice about the surfaces investigated. After cleaning, the degree of purity signifi- cantly improves in all cases, demonstrated as lower microbiological counts. Only in one case of mechanical cleaning is the internally defined surface hygiene standard, with the minimal limit of 50 CFU, not reached after the cleaning (Table 4). M. Jevšnik, A. Ovca, P. Raspor A comparison of three different cleaning methods for reducing contaminants on contact surfaces... International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 61  The microbiological investigation of cleaning solutions was on average between 8 and 11 CFU/mL, which is lower than the internally defined action limit (100 CFU/mL). The microbiological investigation of swabs taken from cleaning wipes yielded no microbiological counts (CFU). Calculating the results from Table 4 into an average cleaning effective- ness according to the cleaning type, we can observe the higher effi- ciency of box system and two-bucket system at all sampling points when compared to the mechanical cleaning (Figure 1), which is contra- ry to the results obtained with the GloGerm® method. However, we have to consider that the microbiological counts before cleaning were higher in the case of mechanical cleaning (Table 4). This could be relat- ed to the greater frequency of workload in comparison to the other two areas evaluated. Another reason for the lower efficiency of mechanical cleaning could be related to the fact that after the mechanical cleaning procedure is accomplished more water is still present on the surface in comparison to the box system and two-bucket system. Closer examination of the cleaning performance according to the sam- pling point indicates that effectiveness is also related to the accessibility of the cleaning area during the cleaning procedure. Sampling point 6, located in the middle of the room, has the lowest discrepancy in the cleaning efficiency when all three cleaning methods are compared (Fig- ure 1). In addition, the cleaning efficiency in the case of sampling point 1 (not considering the cleaning type) is generally better compared to table 4: Microbiological situation (CFU/mL) before and after cleaning at the surface after microbiological examination of surface sampling in three sequences of (two samples in one sequence) according to the cleaning type and the sampling point Cleaning type Sampling sequence Sampling interval CFu/ml at each sampling point 1 2 3 4 5 6 Box system 1st BC 41 4 13 15 22 97 AC 0 0 0 3 0 2 2nd BC 13 4 11 13 2 8 AC 0 2 0 0 0 0 3rd BC 16 6 2 3 3 10 AC 0 2 0 0 0 1 Double bucket system 1st BC 9 12 18 9 1 2 AC 2 0 0 0 0 0 2nd BC 6 3 5 72 15 5 AC 0 0 0 2 0 0 3rd BC 21 30 7 3 19 4 AC 0 1 2 1 0 0 Mechanical cleaning 1st BC 53 67 91 107 59 44 AC 7 23 1 3 2 0 2nd BC 45 47 68 58 23 6 AC 6 46 7 39 13 1 3rd BC 93 31 120 55 31 29 AC 3 1 69 21 10 2 Legend: BC – Before cleaning; AC – After cleaning M. Jevšnik, A. Ovca, P. RasporA comparison of three different cleaning methods for reducing contaminants on contact surfaces... © Inštitut za sanitarno inženirstvo, 201762  sampling points 2–4 in spite of their locations, which are quite similar. This also indicates that the cleaning direction is important. The area of sampling point 1 was cleaned first in the case of all three cleaning types, which is again contrary to the results gained with GloGerm® method (Table 3) where sampling point 1 was (other than sampling point 6) evaluated as at the least effectively cleaned. DISCuSSIon The scarcity of advanced and recent publications in the area of general hygiene management is obvious in scientific literature. If the publica- tions exist, they are focused on particular types of interests, which are frequently about pathogens. Consequently, we lack data that would en- able a comparison of the state of the art in general, and we cannot de- termine the microbial population dynamic in this area of activity. The main focus of each cleaning procedure is to ensure the required levels of cleanliness of different places, the workspace, equipment and other accessories, which all influence the safety, quality, and effectiveness of the final products. This is not only the elimination of particular patho- genic species. Cleaning does not entail the end of a productive proce- dure but the beginning of the procedure of a new product. Therefore, if cleaning is not also taking into account general hygiene, it easily brings the system into a situation in which certain spoilage microflora or even potentially pathogenic flora are accumulating resistance and slowly be- gin to predominate. Therefore, it is of crucial importance to screen this aspect of cleaning efficiency as well. For that reason, we performed this study. Al-Hamad and Maxwell [20] determined that the risk of acquiring infec- tion from environmental surfaces, such as floors, walls, or the surfaces Figure 1: Average cleaning effectiveness (%) according to the cleaning type expressed as a reduction in the number of CFU/mL after cleaning; n – number of sampling sequences M. Jevšnik, A. Ovca, P. Raspor A comparison of three different cleaning methods for reducing contaminants on contact surfaces... International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 63  of medical equipment or furniture, is probably small. However, there is a large body of clinical evidence, derived from case reports and out- break investigations, which does identify links between poor environ- mental hygiene and the transmission of micro-organisms causing hospi- tal-acquired infection. Srey et al. [21] emphasized that pathogenic microorganisms in biofilms formed in different food industries settings are a source of food contamination. As the demand for fresh, ready-to- eat and processed foods increases, many studies are needed to address biofilm removal and disinfectant efficacy in food industries. Sinsheimer et al. [22] showed that professional wet cleaning has been determined as an energy efficient, nontoxic, zero-emission technology, and it can be used to process previously dry cleaned garments. In our study, the monitoring of cleaning effectiveness after applying the box system and the two-bucket system has revealed that test kits applied on the sur- face were often smudged and therefore evaluated as not being suffi- ciently clean. This demonstrates that the cleaning effect is largely de- pendent on the cleaning type applied and cleaning technique applied by the cleaning staff. Sinsheimer et al. [22] also concluded that the clean- ers they studied in California who switched to professional wet cleaning were able to maintain their level of service and customer base while lowering operating costs. They also found that the cleaners were able to transition to professional wet cleaning without a great degree of difficul- ty and were highly satisfied with the new technology [22, 23]. In this preliminary study, according to the GloGerm® method the re- sults indicate that the most effective way of cleaning is mechanical cleaning (Table 3), which is not the case when the microbiological eval- uation is done (Table 4) revealing the discrepancy between the results gained with the generic method compared to conventional microbiologi- cal examination. The results of average cleaning effectiveness according to the cleaning type demonstrated the box system to be the most effi- cient followed by the two-bucket system and the mechanical method (Figure 1). In the case of mechanical cleaning, it should be noted that workload was higher compared to other two areas when this cleaning method was used as intended (Table 4). Another reason for the lower efficiency of mechanical cleaning could be related to the fact that, in comparison to the box and two-bucket systems, after the cleaning pro- cedure is accomplished more water remains present on the surface. Al- though both methods applied for surface hygiene monitoring cannot be directly compared, the contrast between the results of the GloGerm® method and microbiological analysis indicates the need for the valida- tion of generic methods before being applied as a standard way of mon- itoring of surface cleanliness. The absence of a test kit does not neces- sarily also mean a better microbiological situation and vice versa. Moreover, one can observe that the tests applied might be linked to the cleaning process (Table 3). It seems that mechanical cleaning can be handled well with all three test kits, which was not the case with the other two cleaning protocols. Closer examination in other industrial cir- cumstances would also be beneficial to clarify this inconsistency in test reliability. The results of our preliminary study support the conclusions of Griffith et al. [24], who demonstrated that for maximum benefit, vis- M. Jevšnik, A. Ovca, P. RasporA comparison of three different cleaning methods for reducing contaminants on contact surfaces... Cleaning effect is largely dependent on the cleaning type applied and cleaning technique applied by the cleaning staff. © Inštitut za sanitarno inženirstvo, 201764  ual, non-microbiological and microbiological methods should be com- bined, resulting in the production of an integrated cleaning monitoring strategy. Moore and Griffith [2] indicated that conventional microbio- logical techniques would detect only the microbial component of any residual surface contamination. Furthermore, despite the use of hygiene swabs enabling the detection of relatively low levels of bacteria on a wet surface, previous studies have indicated that the recovery of microor- ganisms is severely compromised when the sampled surface is dry. It was ascertained that the accessibility of sampling points is correlated with the effectiveness of the cleaning procedure. An important step in the manufacture of pharmaceutical products, demonstrated by Akl et al. [7], is the cleaning of equipment and surfaces. The cleaning proce- dures for the equipment must be validated according to GMP rules and guidelines. The main objective of cleaning validation is to avoid con- tamination between different productions or cross-contamination [7]. Resto et al. [25] indicated the main requirements for the validation of cleaning processes in the pharmaceutical industry, specifying that no detergent should remain after the cleaning process, what is similar for processes for high hygiene control. The accessibility of sampling points during the cleaning procedure and cleaning direction defined the effec- tiveness of cleaning performance (Table 4, Figure 1) according to the sampling point (e.g. sampling points 5 and 6 located in the middle of the room in case of the double bucket system have higher cleaning effi- ciency in comparison to other sampling points). We estimated good hy- giene practise considering the surfaces investigated before cleaning (e.g. in most cases the number of CFU is low under the internally de- fined action limit (200 CFU)) and after cleaning (e.g. the degree of pu- rity in all cases except one improves, demonstrated as lower microbio- logical counts) (Table 4). For validation of the cleaning process and for continuously educating cleaning staff, quick and objective feedback on the surface cleanliness is of paramount importance [26]. Luick et al. [27] found that subjective and objective measures of cleanli- ness based on visual inspection, ATP assay, or aerobic culture were all able to demonstrate significant increases in the proportion of surfaces considered clean if analysed before and after the routine terminal clean- ing protocol described in this paper. However, if visual inspection were used alone, a significantly higher proportion of surfaces would be con- sidered clean before terminal cleaning. ConCluSIon The evaluation of three different cleaning procedures revealed that cleaning effectiveness depends on the surface accessibility and cleaning direction. Discrepancies between results acquired with a generic meth- od compared to conventional microbiological surface examination in the context of surface hygiene monitoring were discovered. The semi-auto- matic system has shown higher efficiency in comparison to the me- chanical system on surfaces with the same characteristics. We can conclude that an integrated cleaning monitoring strategy should be M. Jevšnik, A. Ovca, P. Raspor A comparison of three different cleaning methods for reducing contaminants on contact surfaces... It was ascertained that the accessibility of sampling points is correlated with the effectiveness of the cleaning procedure. The evaluation of three different cleaning procedures revealed that cleaning effectiveness depends on the surface accessibility and cleaning direction. International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 65  based on a combination of visual, non-microbiological and microbiologi- cal methods for optimal cleaning results. This preliminary study provides vital information in the context of the very small number of publications in the field of general basic hygiene management. Assessing all interactions within cleaning procedures in different hygiene processes, it seems that many issues do not have the attention they deserve. However these kinds of research are internal in its nature and have often a confidential status. Despite of lack of pub- lished studies in this field, this kind of research is constantly underway in processes of high hygiene control including the one participating in current study, as this is one way of ensuring adequate product quality. This is of particular importance, as results of our preliminary study might serve as a basis for further professional and scientific research. This preliminary study’s findings suggest that future research should ex- plore these themes in greater depth. lIMItAtIonS oF tHE StuDY The reader of this paper should take into consideration a few limitations of the current study, which is of a preliminary nature. The study was conducted in a single institution for the processes of high hygiene con- trol with a modest sample size and minimal sampling sequences. There was no intention to validate a generic method for surface hygiene evalu- ation. Smaller surfaces were evaluated under semi-controlled circum- centres with regards to the cleaning solution, surface characteristics and location of sampling points. The possible effect of the cleaning staff was not considered. REFEREnCES [1] Sandle T. Cleaning and disinfection. Pharm Microbiol 2016; 0: 185–197. [2] Moore G, Griffith CA. Comparison of traditional and recently developed methods for monitoring surface hygiene within the food industry: an industry trial. Int J Environ Heal R 2002; 12: 317–29. [3] Lelièvre C, Antonini G, Faille C et al. Cleaning-in-place Modelling of Cleaning Kinetics of Pipes Soiled by Bacillus Spores Assuming a Process Combining Removal and Deposition. Trans IChemE 2002; 80: 305–11. [4] Prabu L, Suriya Prakash TNK, Thirumurugan R. Cleaning Validation and Its Regulatory Aspects in the Pharmaceutical Industry Developments in Surface contamination and Cleaning, 2016; 0: 129–186. [5] Prabu L, Suriya Prakash TNK. Cleaning Validation and its importance in Pharmaceutical Industry. Pharma Times 2010; 42(07): 21–25. [6] Quinn MM, Henneberger PK. Cleaning and disinfecting environmental surfaces in health care: Toward an integrated framework for infection and occupational illness prevention. Am J Infect Control 2015; 43: 424–34. [7] Akl MA, Ahmed MA, Ramadan A. Validation of an HPLC-UV method for the determination of ceftriaxone sodium residues on stainless steel surface of pharmaceutical manufacturing equipments. J Pharm Biomed Anal 2011; 55: 247–252. [8] Dubey N, Dubey N, Mandhanya M, et al. Cleaning level acceptance criteria and HPLC-DAD method validation for the determination of Nabumetone residues on manufacturing equipment using swab sampling. J Pharm Anal 2012; 2(6): 478–483. M. Jevšnik, A. Ovca, P. RasporA comparison of three different cleaning methods for reducing contaminants on contact surfaces... Assessing all interactions within cleaning procedures in different hygiene processes, it seems that many issues do not have the attention they deserve. © Inštitut za sanitarno inženirstvo, 201766  [9] Peles DN, Elya KJ, Crowdera TM, et al. Rapid at-line pharmaceutical cleaning verification using a novel light induced fluorescence (LIF) sensor. J Pharm Biomed Anal 2013; 72: 1–7. [10] Fourman GL, Mullen MV. Determining cleaning validation acceptance limits for pharmaceutical manufacturing operations, Pharm Technol 1993; 17: 54–60. [11] Forsyth RJ, Nostrand VV, Martin GP. Visible-residue limit for cleaning validation and its potential application in a pharmaceutical research facility. Pharm Technol 2004; 28: 58–72. [12] Griffith CJ, Cooper RA, Gilmore J, et al. 2000. An evaluation of hospital cleaning regimes and standards. J Hosp Infect 45: 19–28. [13] Dancer SJ. The role of environmental cleaning in the control of hospital- acquired infection. J Hosp Infect 2009; 73: 378–85. [14] Tebbutt G, Bell V, Aislabie J. Verification of cleaning efficiency and its possible role in programmed hygiene inspections of food businesses undertaken by local authority officers. J Appl Microbiol 2007; 102: 1010–1017. [15] Oberyszyn AS, Robertson FM. Novel Rapid Method for Visualization of Extent and Location of Aerosol Contamination During High-Speed Sorting of Potentially Biohazardous Samples. Cytometry 2001; 43: 217–222. [16] Carrascosa C, Saavedra P, Millán R, et al. Monitoring of cleanliness and disinfection in dairies: Comparison of traditional microbiological and ATP bioluminescence methods. Food Control 2012; 28: 368–373. [17] Calvert RM, Hopkins HC, Reilly MJ, et al. Caged ATP – an internal calibration method for ATP bioluminescence assays. Lett Appl Microbiol 2000; 30: 223–27. [18] Regulation (EC) No 648/2004 of the European parliament and of the council of 31 March 2004 on detergents. Official Journal of the European Union L 104/1-35. [19] ISO 18593:2004. Microbiology of food and animal feeding stuffs – Horizontal methods for sampling techniques from surfaces using contact plates and swabs. [20] Al-Hamad A, Maxwell S. How clean is clean? Proposed methods for hospital cleaning assessment. J Hosp Infect 2008; 70: 328–34. [21] Srey S, Jahid IL, Ha SD. Biofilm formation in food industries: A food safety concern. Food Control 2013; 31(2): 572–585. [22] Sinsheimer P, Grout C, Namkoong A, et al. The viability of professional wet cleaning as a pollution prevention alternative to perchloroethylene dry cleaning. J Air Waste Manag Assoc 2007; 57: 172–178. [23] Onasch J. A feasibility and cost comparison of perchloroethylene dry cleaning to professional wet cleaning: case study of Silver Hanger Cleaners, Bellingham, Massachusetts. J Clean Prod 2011; 19(5): 477– 82. [24] Griffith CJ, Davidson CA, Peters AC, et al. Towards a strategic cleaning assessment programme: hygiene monitoring and ATP luminometry, an options appraisal. Food Sci Tech Today 1997; 11: 15–24. [25] Resto W, Hernández D, Rey R, et al. Cleaning validation 2: Development and validation of an ion chromatographic method for the detection of traces of CIP-100 detergent. J Pharmaceut Biomed 2007; 44: 265–69. [26] Amodio E, Dino C. Use of ATP bioluminescence for assessing the cleanliness of hospital surfaces: A review of the published literature (1990–2012). J Infect Public Health 2014; 7: 92–98. [27] Luick L, Thompson PA, Loock MH, et al. Diagnostic assessment of different environmental cleaning monitoring methods. Am J Infect Control 2013; 41(8):751–2. M. Jevšnik, A. Ovca, P. Raspor A comparison of three different cleaning methods for reducing contaminants on contact surfaces... © Inštitut za sanitarno inženirstvo, 2017 International Journal of sanitary engineering researchVol. 11  No. 1/2017 S it r Engineering Research 67 Is the knowledge of international travel health a legal obligation or a social and personal responsibility? 1 University of Ljubljana, Faculty of Health Sciences, Zdravstvena pot 5, Ljubljana, Slovenia E-mail: zrinski.zarja@gmail.com Zarja ZRInSKI1 ABStRACt The preservation of health is a crucial aspect in the development of international travel. The aim of this literature review was to analyse the issues of travel- related helath risks and the possibilities of prevention. As the destination changes, hazards differ. Health hazards depend on the cultural, infrastructural, technological, enviromental aspects of tourists locations. The process of health promotion helps travellers to gather necessary information about the destination and to accomplish a safe travel. By taking precautions and complying with safety requirements, travellers avoid the spread of diseases. The knowledge of international travel health is a legal obligation and an important responsibility for every traveller. key words: international travel, hazards, health promotion, travellers The article was created on the basis of the Roy Emerson winning Essay – Literature Review, subbmited to The International Federation of Health and presented at the One Health Conference in October 2017. Received: 24. 11. 2017 Accepted: 30. 11. 2017 Professional paper  © Inštitut za sanitarno inženirstvo, 201768  IntRoDuCtIon Travel medicine is concerned with the prevention and treatment of trav- el-related disease [1]. The objectives of the pre-travel consultation are to assess the traveler’s trip plans and determine potential health haz- ards [2]. The consultation includes information about the most impor- tant health risks, including traffic accidents [3]. This speciality is in- creasingly comprehensive and encompasses the epidemiology of travel-related infection, the pre-travel consultation with advice on pre- vention, vaccination, chemoprophylaxis and self-treatment during travel. In Europe, pre-travel preventive advice follows national guidelines or WHO recommendations [1]. The likelihood of disease and injury connected with the trip depends on traveller and itinerary specific factors [4]. The consultation should take place at least 4–8 weeks before the journey and preferably earlier if long-term travel or overseas work is envisaged. Travellers with underly- ing medical problems are strongly advised to consult a travel medicine clinic or medical practitioner to ensure that their potentially complex travel health needs are met [3]. MEtHoDS Literature review and an analysis of the issue based on the current pub- lications and agreed International Travel Health Controls to manage public health risks. Considering disease information, vaccination, travel health risks including: environmental risks, infectious disease & poten- tial risks, accidental injury and speed of pan continental transmission including controls to minimise the global public health risks. Sistematic literature research including implications of international travel health and basic health hazard prevention. Evaluating the theory of corelation between legal obligations and the viewpoint on social and personal responsibility. The literature review includes articles with the publication year between 1994 and 2017. Articles are available at the online scientific service Web of Science. lItERARY AnAlYSIS AnD DISCuSSIon vaccination Vaccinations are a principal measure of pre-travel preparation and they most probably constitute the most frequent reason for which an interna- tional traveller requests consultation prior to depart [5]. Travel vaccines include routine vaccines already incorporated in the national immuniza- tion program, required vaccines necessary for entry into certain countries and recommended vaccines whose recommendation depends on the risks of exposure at travel destination [3]. Risk assessment should be in- dividualized on the basis of the epidemiological situation at destination, travel characteristics and traveller’s characteristics. In addition, pre-travel consultation provides a timely opportunity for updating routine vaccina- tions [6]. The vaccines that may be recommended or considered for trav- ellers are summarized in Table 1. Z. Zrinski Is the knowledge of international travel health a legal obligation or a social and personal responsibility? The objectives of the pre-travel consultation are to assess the traveler’s trip plans and determine potential health hazards. Vaccinations are a principal measure of pre-travel preparation and they most probably constitute the most frequent reason for which an international traveller requests consultation prior to depart. International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 69  table 1: Vaccines that may be recommended or considered for travellers [3] cAtEgoRY vACCInE 1. Routine vaccination Diphtheria, tetanus, and pertussis Hepatitis B Haemophilus influenzae type b Human papillomavirusa Influenzab Measles, mumps and rubella Pneumococcal disease Poliomyelitis Rotavirusa Tuberculosisc Varicella 2. Selective use for travellers to destinations of particular risksd Cholera Hepatitis Ae Japanese encephalitise Meningococcal diseasee Rabies Tick-borne encephalitise Typhoid fever yellow fevere 3. Required vaccination yellow fever Meningococcal disease against serogroups A, C, y and W135 (Saudi Arabia demands proof of recent meningococcal vaccination (tetravalent vaccine) as a visa requirement for pilgrims and guest workers) and polio (required by Saudi Arabia for pilgrims) a To date, introduced into the routine immunization programme of a limited number of countries. b Routine vaccination for certain age groups and also for individuals belonging to certain high-risk groups. c No longer routine in most industrialized countries. d For diseases in this category a summary of vaccine recommendations and other precautions is provided. e These vaccines are also included in the routine immunization programme in several high-risk countries. EnvIRonMEntAl RISkS Travellers often experience abrupt and dramatic changes in environmen- tal conditions, which may have detrimental effects on health and well- being. Travel may involve major changes in altitude, heat and humidity, and exposure to microbes, animals and insects. The negative impact of sudden changes in the environment can be minimized by taking simple precautions [3]. Altitude Altitude illness commonly affects unacclimatized individuals traveling to altitudes over 2500 m. The term refers to a number of diagnoses in- cluding acute mountain sickness, which is most common, as well as the more severe high altitude cerebral edema and high altitude pulmo- nary edema [7]. Acute mouintain sickness symptoms are nonspecific, with the diagnosis being defined as the presence of headache plus one or more of the following: gastrointestinal upset (anorexia, nausea, or vomiting), sleep disturbance, dizziness, and fatigueinan individual re- cently arrived at altitude [8]. Z. ZrinskiIs the knowledge of international travel health a legal obligation or a social and personal responsibility? Altitude illness commonly affects unacclimatized individuals traveling to altitudes over 2500 m. © Inštitut za sanitarno inženirstvo, 201770  Only a few conditions are contraindications for travel to altitude; they include unstable angina, pulmonary hypertension, severe chronic ob- structive pulmonary disease and sickle-cell anaemia [3]. Travellers should avoid one-day travel to sleeping altitudes over 2750 m if possible and break the journey for at least one night at 2000–2500 m to help prevent acute mountain sickness. They must avoid overexer- tion and alcohol for the first 24 h at altitude and drink extra water. If direct travel to sleeping altitude over 2750 m is unavoidable, they should consider prophylaxis with acetazolamide. Travellers with pre-ex- isting cardiovascular or pulmonary disease should seek medical advice before travelling to high altitudes [3]. Heat and humidity The mechanism by which heat impacts humans is complex, and al- though it is often treated as a sole product of temperature, in reality it is a result of the interactions between temperature, radiation, wind, and humidity. Despite its physiological importance, humidity is rarely the explicit focus in health impact studies [9]. Heat-related illnesses can manifest in occupations that demand a high amount of physical work in high ambient temperatures [10]. Consumption of salt-containing food and drink helps to replenish the electrolytes in case of heat exhaustion and after excessive sweating. Travellers should drink enough fluid to be able to maintain usual urine production. A daily shower using soap, wearing loose cotton clothing and applying talcum powder to sensitive skin areas help to reduce the development or spread of fungal skin infections. Travellers should avoid contact lenses in order to reduce the risk of eye problems [3]. Foodborne diseases The food chain has undergone considerable and rapid changes over the last 50 years, becoming highly sophisticated and international. Al- though the safety of food has dramatically improved overall, progress is uneven and food-borne outbreaks remain common in many countries [11]. Examples of diseases acquired through food and water consumption are travellers’ diarrhoea, hepatitis A, typhoid fever and cholera [3]. Many infectious diseases, including a variety of gastrointestinal disor- ders, are contracted by individuals while travelling outside their country of residence [12]. As a result, someone can be exposed to a foodborne illness in one country and expose others to the infection in a location thousand of miles away from the original source of infection [12, 13]. In order to reduce the number of foodborne outbreaks, a regulatory in- ternational framework for food production and food safety has been de- veloped over the last few years. European Union legislation on food hy- giene focuses on the controls needed for public health protection and clarifies the responsibility of food business operators to produce food safely [14]. Z. Zrinski Is the knowledge of international travel health a legal obligation or a social and personal responsibility? Travellers should avoid one-day travel to sleeping altitudes over 2750 m if possible and break the journey for at least one night at 2000–2500 m to help prevent acute mountain sickness. Heat-related illnesses can manifest in occupations that demand a high amount of physical work in high ambient temperatures. International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 71  Measures to prevent foodborne diseases include diet (foods and bever- ages to be avoided) and hygiene (boiling water or treating it with chlo- rine or iodine preparations, washing hands before eating) [15]. Waterborne diseases Waterborne diseases refer to any disease that can be transmitted through water, which is mainly via pathogen ingestion. However, many other potential transmission routes, such as eating food touched by an individual with soiled hands, drinking sewagecontaminated water, or contacting an infected individual during treatment in a hospital, may ac- count for the spread of waterborne diseases [16]. Access to safe drinking water is essential to health, a basic human right and a component of effective policy for health protection. Travellers should avoid consumption or use of unsafe water, avoid unpasteurized juices, ice made from untreated water, salads or other uncooked melas. They should drink water that has been bolied, filtered or treated with chlorine or iodine and sotred in clean containers, bottled water and bev- erages from sealed and tamper-proof containers, pasteurized juices and pasteurized milk [17]. Animals Animal bites have serious medical consequences including trauma, wound infection, exposure to rabies virus and social costs for the bitten individuals, and lead to thousands of deaths and injuries [18]. Taking care of animal bite-related injuries can provide useful information for planning and evaluation of public health interventions [19]. Rabies is the most important infectious health hazard from animal bites. In many developing countries, rabies is transmitted mainly by dogs, but many other mammalian species can be infected by the rabies virus [3]. Travellers should avoid direct contact with domestic animals in areas where rabies occurs, and with all wild and captive animals, behaviour that may startle, frighten or threaten an animal. A number of rabies-free countries have additional requirements. Before taking an animal abroad, the traveller should ascertain the regulatory requirements of the coun- tries of destination and transit [3]. Snake bites Snake bite prevention suggests avoiding all contact with snakes, even if believed to beharmless or dead, wearing protective clothing (boots not open sandals, socks, long trousers) in undergrowth or deep sand, using a light at night. Travellers should sleep off the ground, under a well- tucked-in mosquito net or on a sewn-in groundsheet to prevent noctur- nal bites [20]. Scorpion stings and spider bites Dangerously venomous scorpions inhabit deserts or hot dusty terrains. Dangerous spiders occur in the Americas, the Mediterranean, southern Z. ZrinskiIs the knowledge of international travel health a legal obligation or a social and personal responsibility? Measures to prevent foodborne diseases include diet (foods and beverages to be avoided) and hygiene (boiling water or treating it with chlorine or iodine preparations, washing hands before eating). Travellers should avoid consumption or use of unsafe water, avoid unpasteurized juices, ice made from untreated water, salads or other uncooked melas. © Inštitut za sanitarno inženirstvo, 201772  Africa and Australia. Travellers should use a permethrin-impregnated bed net, sleep off the ground, treat living quarters with insecticides and not walk bare-footed [21]. Aquatic bites and stings Many freshwater and marine venomous fish, including stingrays, cat- fish, weevers, scorpion fish and stonefish, have venomous stinging spines on their gills, fins or tail [20]. Prevention of aquatic bites and stings includes the observation of local advice and warning notices before entering the water. Wetsuits and footwear prevent sea snake bites and jellyfish stings. Swimming pools The safety of swimming in pools is susceptible by a large variety of risks, including microbiological agents, chemical agents and technologi- cal and work related hazards [22]. The risk of illness or infection asso- ciated with swimming pools and similar recreational water environments is primarily associated with faecal contamination of the water. There are over 50 types of adenoviruses that have been linked to swimming pool outbreaks. In some countries, it is common to shower before a swim. Showering will help to remove traces of sweat, urine, faecal matter, cosmetics, suntan oil and other potential water contaminants. Where pool users normally shower before swimming, pool water is cleaner, easier to disin- fect with smaller amounts of chemicals and thus more pleasant to swim in [23]. Coastal and fresh waters In coastal waters, infection may result from ingestion or inhalation of, or contact with, pathogenic microorganisms, which may be naturally present, carried by people or animals using the water, or present as a result of faecal contamination [3]. Travellers should use life jackets where appropriate, pay attention to, and seek information from local residents regarding, tides and currents, and avoid outlets in spas and swimming pools. They should ensure con- stant adult supervision of children in or near recreational waters, includ- ing small volumes of water and avoid consumption of alcohol before any activity in or near water [3]. Parasites A parasite is an organism that lives on or in a host organism and gets its food from or at the expense of its host. There are three main classes of parasites that can cause disease in humans: protozoa, helminths, and ectoparasites. Travellers should avoid walking barefoot, as parasites can enter intact or damaged skin [24]. Z. Zrinski Is the knowledge of international travel health a legal obligation or a social and personal responsibility? The safety of swimming in pools is susceptible by a large variety of risks, including microbiological agents, chemical agents and technological and work related hazards. International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 73  InFECtIouS DISEASES AnD PotEntIAl RISkS Infectious diseases constitute one important aspect of travel associated risks. Despite possibilities of prevention by means of vaccinations and other preventive measures, vaccine preventable diseases remain an im- portant contributor to morbidity in travellers [25]. Travellers as tourists or occupational travellers will encounter a range of infectious agents at the destination that differ greatly from those of home especially when visiting low income, tropical countries [1]. Zoonotic diseases Zoonotic diseases are described as those diseases transmitted from ani- mals to humans. While the transmissive stages of zoonoses can be transmitted directly (e.g. by animal human contact or through contact with contaminated faeces, soil and herbage), they can also be transmit- ted through contaminated water and food [26]. The risk of infection can be reduced by avoiding close contact with any animals – including wild, captive and domestic animals in places where infection is likely to be present. Particular care should be taken to pre- vent children from approaching or touching animals [3]. Sexually transmitted infections Sexually Transmitted Diseases (STDs) are diseases that are passed on from one person to another through sexual contact, and sometimes by genital contact – the infection can be passed on via vaginal intercourse, oral sex, and anal sex [27]. The risk of infection can be reduced by avoiding casual and unprotected sexual intercourse and by use of condoms [3]. Bloodborne diseases and diseases transmitted via soil Bloodborne diseases are transmitted by direct contact with infected blood or other body fluids. The risk of infection can be reduced by avoiding di- rect contact with blood and body fluids. Soil-transmitted diseases include those caused by dormant forms (spores) of infectious agents, which can cause infection by contact with broken skin. The risk of infection can be reduced by protecting the skin from direct contact with soil in places where soil-transmitted infections are likely to be present [3]. The risk of contracting a soil-transmitted disease can be high when getting a tattoo abroad. Travellers should make sure that all tattoo equipment is fully sealed, within date, sterilised and opened in front of them. Airborne diseases People encounter and have contacts with others in conducting activities or traveling; thus, they may become infected with air- borne viruses when epidemics are prevalent [28]. Airborne transmission occurs when droplet nuclei <5 μm in size are disseminated in the air and breathed in. Droplets are usually generated by the infected individual during coughing, sneezing or talking [3]. Z. ZrinskiIs the knowledge of international travel health a legal obligation or a social and personal responsibility? Airborne transmission occurs when droplet nuclei <5 μm in size are disseminated in the air and breathed in. Droplets are usually generated by the infected individual during coughing, sneezing or talking. © Inštitut za sanitarno inženirstvo, 201774  The probability that a susceptible person becomes infected during a visit to a sublocation depends on: how many infectious persons co-oc- cupy the room, how long each contact lasts, the type of activity, and the infectiousness category of the infectious person [28]. ACCIDEntAl InJuRY Unintentional injury is a global public health problem. Reasons for the increasing public health importance of injury include the decline of in- fectious disease, the processes of urbanization, industrialization, motor- ization, and increased opportunities to travel [29]. Motor vehicle crashes, drownings, aircraft crashes, homicides, and burns can cause fatal injury deaths to travelers. Injuries to travelers are not random events. As with other health problems such as infectious diseases, injuries are preventable. Injury prevention and control is a sci- ence with fundamental principles and a growing knowledge base [30]. traffic injury Road traffic injuries constitute a major public health and development crisis, and are predicted to increase if road safety is not addressed ade- quately [31]. Precautions in the countries to be visited include obtaining information on the regulations governing traffic and vehicle maintenance and on the state of the roads. Travellers should not drive after drinking alcohol, drive with- in the speed limit at all times, always wear a seat-belt. In addition, travel- lers driving vehicles abroad should make sure they carry their personal driving licence as well as an international driving permit and that they have full insurance cover for medical treatment of injuries [3]. Drownings Drowning is an important public health issue with major impacts on children and youth. Drowning is preventable. Lack of barriers controlling exposure to water bodies and lack of adequate, close supervision for in- fants and young children are a drowning risk, as are poor swim skills and low awareness of water dangers. In addition, high-risk behaviour, including consuming alcohol while engaging with water, is a risk among young people and adults. Other risk factors are transport on water and water crossings, lack of safe water supply, and flood disasters [32]. SPEED oF PAn ContInEntAl tRAnSMISSIon Today’s highly mobile, interdependent and interconnected world pro- vides myriad opportunities for the rapid spread of diseases. A number of factors have underscored the fact that infectious disease events in one country may be of potential concern for the entire world. These fac- tors include: increased population movements; growth in international trade in food; biological, social and environmental changes linked with urbanization; deforestation; alterations in climate; and changes in meth- Z. Zrinski Is the knowledge of international travel health a legal obligation or a social and personal responsibility? Today’s highly mobile, interdependent and interconnected world provides myriad opportunities for the rapid spread of diseases. International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 75  ods of food processing, distribution and consumer habits. Consequent- ly, the need for international cooperation in order to safeguard global health has become increasingly important. It is critical that all countries have the capacity to detect, assess, and respond to public health events. They will then be able to contain the spread of diseases within their borders, thus minimizing the international spread of diseases [33]. ConCluSIon Information, epidemiological data and surveillance are fundamental to obtain reliable information about the local health status and to prevent potential health problems. Vaccination entry requirements, road traffic safety requirements, food safety requirements and other specifications confirm the improtance of public health. By taking simple precautions, that are described in this essay, travellers avoid plenty of risks and pre- vent the spread of diseases. Every traveller should travel safely and should be responsible for protecting the health of others and his own health. Keeping healthy is not only a common personal priority and a moral issue, but it is also a legal obligation. REFEREnCES [1] Schlagenhauf P, Weld L, Goorhuis A, et al. Travel-associated infection presenting in Europe (2008–12): an analysis of EuroTravNet longitudinal, surveillance data, and evaluation of the effect of the pre-travel consultation. The Lancet Infectious Diseases 2015; 15 (1): 55-64. [2] CENTERS FOR DISEASE CONTROL AND PREVENTION, et al. CDC health information for international travel 2014: The yellow book. Oxford University Press, 2013. [3] WORLD HEALTH ORGANIZATION. International travel and health: situation as on 1 January 2012. World Health Organization, 2012. [4] Bazemore AW, Huntington M. The pretravel consultation. Am Fam Physician 2009; 80 (6): 15. [5] Lau S, Gherardin T. Travel vaccination 2007. Aust Fam Physician 2007; 36: 304e. [6] The Pretravel Consultation – Chapter 2. Centers for Disease Control and Prevention. [online]. 2017. [Accessed 24 March 2017]. 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ZrinskiIs the knowledge of international travel health a legal obligation or a social and personal responsibility? Keeping healthy is not only a common personal priority and a moral issue, but it is also a legal obligation. © Inštitut za sanitarno inženirstvo, 201776  [13] Käferstein FK, Motarjemi y, Bettcher DW. Foodborne disease control: a transnational challenge. Emerging infectious diseases 1997; 3 (4): 503. [14] Balzaretti CM, Marzano MA. Prevention of travel-related foodborne diseases: Microbiological risk assessment of food handlers and ready-to- eat foods in northern Italy airport restaurants. Food control 2013; 29 (1): 202-207. [15] Hill DR, Ryan ET. Management of travellers’ diarrhoea. Bmj 2008; 337: a1746. [16] Wang y, Cao J. Global stability of a multiple infected compartments model for waterborne diseases. Communications in Nonlinear Science and Numerical Simulation 2014; 19 (10): 3753-3765. [17] WORLD HEALTH ORGANIZATION. Guidelines for drinking-water quality. World Health Organization 2004. [18] Wunner WH, Briggs DJ. Rabies in the 21st century. PLoS neglected tropical diseases 2010; 4 (3): e591. [19] Emet M., et al. Animal-related injuries: epidemiological and meteorogical features. Annals of agricultural and environmental medicine 2009; 16 (1): 87-92. [20] Warrell DA. Treatment of bites by adders and exotic venomous snakes. Bmj 2005; 331 (7527): 1244-1247. [21] Warrel DA. Venomous animals. Medicine 2007; 35(12): 659-662. [22] WORLD HEALTH ORGANIZATION, et al. Guidelines for safe recreational water environments. Volume 1: coastal and fresh waters. World Health Organization 2003. [23] WORLD HEALTH ORGANIZATION, et al. Guidelines for safe recreational water environments. Volume 2: Swimming pools and similar environments. World Health Organization 2006. [24] CDC – Parasites – About Parasites. Centers for Disease Control and Prevention. [online]. 2016. [Accessed 1 April 2017]. Available from: https://www.cdc.gov/parasites/about.html. [25] Boggild AK, Castelli F, Gautret P. Vaccine preventable diseases in returned international travelers: results from the GeoSentinel Surveillance Network. Vaccine 2010; 28 (46): 7389-7395. [26] Slifko TR, Smith HV, Rose JB. Emerging parasite zoonoses associated with water and food. International journal for parasitology. 2000; 30 (12): 1379-1393. [27] Nordqvist C. Medical News Today. Sexually transmitted diseases (STDs): Types and symptoms. [online]. 2015. [Accessed 1 April 2017]. Available from: http://www.medicalnewstoday.com/articles/246491. php. [28] Eubank S., et al. Modelling disease outbreaks in realistic urban social networks. Nature 2004; 429 (6988): 180-184. [29] McInnes RJ, Williamson LM, Morrison A. Unintentional injury during foreign travel: a review. Journal of travel medicine 2002; 9 (6): 297- 307. [30] Hargarten SW. Injury prevention: a crucial aspect of travel medicine. Journal of Travel Medicine 1994; 1 (1): 48-50. [31] Peden, M. World report on road traffic injury prevention 2004. [32] WORLD HEALTH ORGANIZATION, et al. Global report on drowning: preventing a leading killer. World Health Organization, 2014. [33] WORLD HEALTH ORGANIZATION, et al. International Health Regulations (2005): Areas of work for implementation 2007. Z. Zrinski Is the knowledge of international travel health a legal obligation or a social and personal responsibility? The publication of an article in a peer-reviewed journal is an es- sential model for “International Journal of Sanitary Engineering Research”. It is necessary to agree upon standards of expected ethical behaviour for all parties involved in the act of publishing: the author, the journal editor, the peer reviewer and the publisher. Our ethic statements are based on COPE’s Best Practice Guide- lines for Journal Editors. Publication decisions The editor is responsible for deciding which of the articles sub- mitted to the journal should be published. 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Chicago: American Medical Assotiation, 1985. [4] Mansfieid LW. How the nurse learns which imbal- ance is present. V: Moidel HC, Sorensen GE, Giblin EC, Kaufman MA, eds. Nursing care of the patient with medical-surgical disorders. New york: Mc Grow-Hill, 1971: 153–60. [5] Evaluation of the European Agency for Safety and Health at Work: http://osha.europa.eu/publications/ other/20010315/index_1.htm (20. 12. 2006).  Instructions for Authors International Journal of Sanitary Engineering Research Vol. 11  No. 1/2017 79 Vol. 11  No. 1/2017International Journal of Sanitary Engineering Research80 Annual subscription: 160 € including postage. Journal IJSER is sponsored by Slovenian Research Agency – ARRS. IJSER shall not take any responsibility for the contents of articles published in the journal and all such responsibility shall lie with the author/s. The opinions expressed in the articles are solely of the author/s and IJSER may not agree with such opinions in part or in full. 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