Preventing Workplace Asthma:
Consider the Cleaning Products
June 7, 2007
Elise Pechter MPH, CIH
Massachusetts Depart Public Health
Anila Bello MS Doctoral Candidate
University of Massachusetts Lowell
Outline
Case studies
Asthma
– Work-related asthma
– Focus on health care workers
Exposure to cleaning agents
– Inhalation
– Dermal
Disinfectants marketed
Recommendations
Incident—Small community
hospital
Cluster of respiratory problems among
operating room staff 9/2005
18 employees to Employee Health
2 employees persistent WAA, reported to
OHSP as WRA (October 2005). Unable
to return to work in OR
Incident and causes
Persistent leaks into OR
Planned repair on HVAC
Moved equipment in
preparation for relocation
Planned repair of airhandling unit
Extra OR cleaning
Prompt action by hospital
Four Possible Exposures
Silicone sealant used in repairing AHU
Fungi, mold, bacteria from previous leaks
Dust from moving OR equipment
HB Quat and other disinfectants and
cleaners used in OR
Quaternary ammonium compound
(“quats”) most likely agent
AOEC list has two “quats” as
recognized asthmagens
Hospital kept two workers out of the
OR for 6-7 months
Changed cleaning chemical from HB
Quat to PCMX, workers returned—
only temporary solution
Quaternary ammonium compound
(“quats”) most likely agent
Two “quats”
recognized
asthmagens
Two workers out of
the OR for 6-7
months
Changed cleaning
chemical from HB
Quat to PCMX,
workers returned—
only temporary
solution
59 y/o Haitian woman had
episodic shortness of breath
while walking, climbing,
carrying. Recalled symptoms
for previous 5 years. Worked
with cleaning agents as
housekeeper for 26 years in
same urban hospital.
Cleaning products contained
quaternary ammonium
compounds (quats), phenols.
Public Health Impact of Asthma*
20.7 million adults reported asthma (8.9
million children)
Adult asthma
– 12.9 million office visits for asthma
– 1.7 million ED visits for asthma
Children have higher rates than adults, but
asthma is an adult disease
http://www.cdc.gov/nchs/fastats/asthma.htm
Sentinel Event Notification System
for Occupational Risks
(SENSOR)
Active state-based surveillance for ‘sentinel’
work-related conditions
Focus on prevention-oriented workplace
intervention
Funded by National Institute for
Occupational Safety and Health (NIOSH)
Surveillance case definition
Work-related asthma
Health care professional diagnosis
consistent with asthma
AND
An association between symptoms of
asthma and work
Includes both new onset asthma (OA,
RADS) and work-aggravated asthma
Surveillance of Work-Related
Asthma (WRA)
Mandatory reporting of WRA (confirmed
and suspected)
1993 to present, >1100 cases reported, of
whom about 600 have been interviewed
Track industries, occupations and agents
that cause or exacerbate WRA
Design interventions to reduce WRA
Massachusetts Surveillance System for
Work-Related Asthma
Hospital
Discharges
Heath Care
Provider reports
OHSP
Emergency Dept
Visits (65 per year)
Workers’ comp
Worker interview
Medical records
Worker follow-up
Employer follow-up
•Educational materials
•Resources in state
•Worksite investigations
Summary data analysis
Industry-wide interventions
Work-related asthma,1995—2005,
Massachusetts n=550
Health Care Workers
162 cases, 30% of all confirmed cases
85% of HCW are female
88% white
94% work in health care industry
Most likely health care worker with WRA is
a nurse, non-smoker, with allergies
PROVISIONAL DATA
Occupations of health care workers
with work-related asthma, n=162
Nurses
Aides/therapists
Office workers
Technicians
Dental health
Janitor/Food
Other
PROVISIONAL DATA
103
17
14
13
7
5
3
HCW v non-HCW, Work-related
asthma,1995-2005, MA n=550
Health care workers
Non-health care worker
N=162
N=388
85% female
88% white
38% ever smoke
3% currently smoke
58% allergies
46% female
82% white
52% ever smoke
17% currently smoke
47% allergies
57% ER visit
55% ER visit
PROVISIONAL DATA
Health Care Workers—4 states,
1993-1997
• 305 of 1,879 cases = 16%
• Leading exposures
• Cleaning products 24%
• Latex 20%
• Glutaraldehyde 9%
• Chemicals, NOS 9%
• Paints, solvents 7%
American Journal of Industrial Medicine 47:265-275 (2005) Pechter et al.
Focus on cleaning products
Rosenman et al 2003 JOEM 45(5):556-63
Cleaning
product
# cases
Unspecified
104
Bleach
43
Acids, bases,
oxidizers
23
Disinfectants
20
Carpet cleaner
17
Floor stripper/
wax
16
Ammonia
14
Exposures to cleaning agents
Anila Bello
Sustainable Hospitals Project
Department of Work
Environment
University of Massachusetts
Lowell
Scope
Cleaning agents serve different
purposes
– Cleaners : remove surface contaminants
– Disinfectants: destroy microorganisms
– cleaner/disinfectant combination very common
Our focus:
–
Cleaning products used for common cleaning
activities such as : window; counter; washroom;
and floor cleaning
Methods
Investigated products used in five workplaces
Four hospitals
One university
Interviewed environmental health and safety representatives
Collected MSDSs and identified ingredients
Reviewed literature
–
–
Chemical and physical properties
Health effects : respiratory & skin irritation and sensitization
Prioritized ingredients
Toxicity ; Concentration ; Frequency of use
Methods
Observed cleaning tasks in the workplaces
Simulated cleaning tasks
In two bathrooms at UML (small and large)
Measured temperature and humidity
mirror cleaning, toilet bowl cleaning and sink cleaning
Measured airborne exposures
Measured with a Direct Reading Instrument
Measured with integrated methods: EPA-TO-17
Assessed potential for the dermal exposures
DREAM method
Results: what do they contain?
Mixtures of ingredients
Surfactants, solvents, disinfectants, fragrances etc.
50+ ingredients in 18 products
Many irritants and several sensitizers
The most hazardous ingredients
Quaternary ammonium compounds
2-buthoxyethanol
Phenols
Ammonia
Ethanolamine
Exposure routes: airborne and dermal exposure
Measurements of air exposures
Cleaning products contain
volatile
semi-volatile
and non-volatile compounds
Complex mixtures ; very difficult to measure
What to measure for ?
TVOCs
Hazardous ingredients such as 2-BE and “quats”
Several methods are needed –very expensive
Measurements techniques
DRI instrument
Integrated sampling
method
– Sorbent tubes
– Sampling pumps at
60-75 ml/min
– Analysis GS/MS
Results from other studies
(experimental studies)
It takes long time for the air concentrations to go down to the
background level
– At least 24 hours for some compounds
Reference : Peder Wolkoff et al, Sc.Tot. Env 1998 215:135-156
“Risk in cleaning : chemical and physical exposure”
Some compounds such as glycol ethers are released from
the surface after one hour of the application
Reference : Singer et al , Indoor Air 2006 16:179-191
“ Cleaning products and air fresheners :emissions and resulting
concentrations of glycol ethers and terpenoids”
Repeated application of the product on the surface causes
background concentration to build up with time
Reference : Nazaroff et al, Atm. Env. 2004 38:2841-2865
“Cleaning products and air fresheners :exposure to primary and
secondary air pollutants”
Dermal exposure assessment
DREAM categories
140
Potentail exposure
120
Emission
100
Deposition
Transf er
80
60
40
20
0
sink cleaning
toilet bowl
cleaning
mirrorr
cleaning
floor cleaning floor cleaning
1
2
Skin exposures
floor cleaning: new mopping technique
Exposures to “quats”
Case reports : association of asthma with quats
exposure
How are nurses getting exposed ?
Quats are not volatile compounds !!!
–
Very low concentrations in the air (Vincent et al, 2006)
Possible exposure routes:
important for controlling exposures
1.
2.
3.
Dermal exposure
Re-suspended in the air : through dust
Aerosolization
Conclusions
Cleaning agents contain irritants and
sensitizers
Inhalation and dermal exposures should both be
considered for controlling workplace exposures
Air concentrations higher than expected
Dermal exposure could be primary exposure route for
important hazardous ingredients
At risk : not only cleaning workers
– nurses , doctors and patients
entering the room after the tasks are performed
Promotion of Disinfection
Cleaning products have added chemicals
– Hospitals vs schools and homes
– “Remind moms & dads to donate Clorox®
Disinfecting Wipes to the classroom, but make
sure parents bring it themselves! Kids should
not be carrying them.”
“Fear” messages
When/where
What do we recommend!
Use disinfectants only when needed
Promote cleaning
When and where is disinfection needed
(hallway floors?)
Is disinfection achieved with common
practices?
10 minute requirements?
the more - the better?
Are current disinfectants effective?
What do we recommend!
Purchase green cleaning products
available for common cleaning activities
Green seal certified
Purchase safer disinfectants
Use effective PPE (example gloves)
Be aware of health effects