This multidisciplinary collaborative effort will enable built environment and health professionals to work together to improve indoor quality environments.5 To mitigate airborne transmission risks it is necessary to supply effective ventilation with clean outdoor air and avoid recirculating air. The Brazilian standard for healthcare indoor air quality is from 2005 and is now under revision.6 The importance of indoor

environmental quality in healthcare buildings is highlighted worldwide. This movement can be understood as an evolutionary response to sick building syndrome (SBS), a term coined in the 1970s with the proliferation of fully sealed buildings with mechanical ventilation. In 1983, WHO used the term SBS for

the first time to describe situations in which building occupants experience acute health and comfort effects that appear to be linked to the time spent in a building, but no specific illness or cause can be identified. For so-called sick buildings, research has been done relating indoor air quality to diseases and infections.

Healthier buildings The green building movement that started during the 1990s focused much more on energy efficiency and reducing water consumption, culminating in building regulations like LEED,7 and EDGE.9

More, recently all green

buildings certifications are aiming to be ‘healthy’ buildings too. In the case of ‘healthy’ buildings, the

main target is people. What is evaluated is an integral view of indoor environmental quality and responses to human comfort and demands, are also behaviour-related to all users’ health. International Well Building Institute

certification has a specific chapter on perception and human mind, which includes actions at the interface between users and the built environment.10


certification intention has changed to promoting people’s health, covering physical, mental and social health, like the current WHO definition of complete health. Therefore, not only building concepts but also professionals’ mindsets need to be revised based on the updated scientific evidence. The ‘Well Building Standard’ highlights aspects such as the relationship between the various contaminants present in

Figure 2. Brazil map: mortality rate per region. BREEAM8

indoor air and how much they can trigger an allergy or asthma, or do any harm. The concepts evaluated in Well certification include not only air quality, lighting, sound, human comfort, but also water, materials and energy, all focused on users’ health. Some innovative aspects evaluated are nutrition, physical exercises and mental wellbeing. Likewise, lighting in a Well-certified building must be assessed not only by amount of lighting (luminance) and visual requirements appropriate to each function, but also the effects of the built environment on users´ circadian cycle. The circadian cycle is the natural biological regulation between day and night made by the human body through the production of hormones cortisol and melatonin. Cortisol hormone keeps people awake and is also related to stress. This can be mitigated by melanopic lighting, and evaluating photometry rates and melanopic lux.11

Indoor pollutants Care teams that work in ICUs on night shifts have their circadian cycle altered and may become more stressed. This may be one of the reasons why the Brazilian Nursing Council does not allow 24-hour shifts while, on the other hand, the Brazilian Medical Council still allows it.12,13 There are also other building

certifications that assess people and their relationships with built environments. The ‘For Health - Healthy Building Certificate’ follows global movement of healthy buildings and had professionals trained in USA working in Brazil since 2019. The

The concepts evaluated in Well certification include not only air quality, lighting, sound, human comfort, but also water, materials and energy, focusing on user’s health


Healthy Building Certificate was developed by Harvard University, in Boston, USA, and is being implemented in healthy buildings in several countries.14 Joseph Allen, director of Harvard’s

Healthy Buildings Program, wrote how some called ‘persistent damaging chemicals’ at indoor polluted air can harm human health and can impact other cognitive functions.15 For example, the paints and sealants

contain volatile organic compounds (VOC) that can cause headaches, red eyes and throat irritation. Maintaining a healthcare environment, requires walls to be painted during its operation, which is a big challenge even with the use of water- based paints that have less odour and do not harm people so much.

Human comfort The importance of indoor built environments quality is confirmed by the growing interest in human comfort in recent decades. Fabio Bitencourt dedicated a chapter to the topic ‘Comfort: perceptions and sensations’ in a Brazilian Health Surveillance publication.16 The author explains the importance of sustainability, hygrothermal comfort, acoustic comfort, visual comfort, ergonomic comfort in the human rhythm, and circadian cycle in minimising risks, errors and accidents to people in hospitals, all integrated in healthcare building design and construction.17 Regardless of whether the hospital

get an environmental certification or not, all hospitals need to take care of users’ health, so they should control indoor environment aspects and air quality to be healthy hospitals. Water and energy consumption have already been tabled by the Brazilian National Association of Private Hospitals (ANAHP). ANAHP represents 122 big complex associated hospitals, which corresponded to 28,288 beds and 6,665 ICU beds at the end of 2019.18


Source: Brazilian States Health Secretariats, Brazil, 2020.

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