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Dumas O, Varraso R, Boggs KM, Quinot C, Zock JP, Henneberger PK, Speizer FE, Le Moual N, Camargo CA. Association of Occupational Exposure to Disinfectants With Incidence of Chronic Obstructive Pulmonary Disease Among US Female Nurses. JAMA Netw Open 2019; 2:e1913563. [PMID: 31626315 PMCID: PMC6813668 DOI: 10.1001/jamanetworkopen.2019.13563] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
IMPORTANCE Exposure to disinfectants in health care workers has been associated with respiratory health outcomes, including asthma. Despite the biological plausibility of an association between disinfectants (irritant chemicals) and risk of chronic obstructive pulmonary disease (COPD), available data are sparse. OBJECTIVE To investigate the association between exposure to disinfectants and COPD incidence in a large cohort of US female nurses. DESIGN, SETTING, AND PARTICIPANTS The Nurses' Health Study II is a US prospective cohort study of 116 429 female registered nurses from 14 US states who were enrolled in 1989 and followed up through questionnaires every 2 years since. The present study included women who were still in a nursing job and had no history of COPD in 2009, and used data from the 2009 through 2015 questionnaires. Clean and complete data used for this analysis were available in July 2018, and analyses were conducted from September 2018 through August 2019. EXPOSURES Occupational exposure to disinfectants, evaluated by questionnaire and a job-task-exposure matrix (JTEM). MAIN OUTCOMES AND MEASURES Incident physician-diagnosed COPD evaluated by questionnaire. RESULTS Among the 73 262 women included in the analyses, mean (SD) age at baseline was 54.7 (4.6) years and 70 311 (96.0%) were white, 1235 (1.7%) black, and 1716 (2.3%) other; and 1345 (1.8%) Hispanic, and 71 917 (98.2%) non-Hispanic. Based on 368 145 person-years of follow-up, 582 nurses reported incident physician-diagnosed COPD. Weekly use of disinfectants to clean surfaces only (16 786 [22.9%] of participants exposed) and to clean medical instruments (13 899 [19.0%] exposed) was associated with COPD incidence, with adjusted hazard ratios of 1.38 (95% CI, 1.13-1.68) for cleaning surfaces only and 1.31 (95% CI, 1.07-1.61) for cleaning medical instruments after adjustment for age, smoking (pack-years), race, ethnicity, and body mass index. High-level exposure, evaluated by the JTEM, to several specific disinfectants (ie, glutaraldehyde, bleach, hydrogen peroxide, alcohol, and quaternary ammonium compounds) was significantly associated with COPD incidence, with adjusted hazard ratios ranging from 1.25 (95% CI, 1.04-1.51) to 1.36 (95% CI, 1.13-1.64). Associations were not modified by smoking or asthma status (P for interaction > .15). CONCLUSIONS AND RELEVANCE These longitudinal results suggest that regular use of chemical disinfectants among nurses may be a risk factor for developing COPD. If future studies confirm these results, exposure-reduction strategies that are compatible with infection control in health care settings should be developed.
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Affiliation(s)
- Orianne Dumas
- INSERM U1168, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, F-94807, Villejuif, France
- University de Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
| | - Raphaëlle Varraso
- INSERM U1168, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, F-94807, Villejuif, France
- University de Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
| | - Krislyn M. Boggs
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Catherine Quinot
- INSERM U1168, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, F-94807, Villejuif, France
- University de Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
| | - Jan-Paul Zock
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Paul K. Henneberger
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, West Virginia
| | - Frank E. Speizer
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Nicole Le Moual
- INSERM U1168, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, F-94807, Villejuif, France
- University de Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
| | - Carlos A. Camargo
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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52
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Su FC, Friesen MC, Stefaniak AB, Henneberger PK, LeBouf RF, Stanton ML, Liang X, Humann M, Virji MA. Exposures to Volatile Organic Compounds among Healthcare Workers: Modeling the Effects of Cleaning Tasks and Product Use. Ann Work Expo Health 2019; 62:852-870. [PMID: 29931140 DOI: 10.1093/annweh/wxy055] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 05/30/2018] [Indexed: 11/12/2022] Open
Abstract
Objectives Use of cleaning and disinfecting products is associated with work-related asthma among healthcare workers, but the specific levels and factors that affect exposures remain unclear. The objective of this study was to evaluate the determinants of selected volatile organic compound (VOC) exposures in healthcare settings. Methods Personal and mobile-area air measurements (n = 143) from 100 healthcare workers at four hospitals were used to model the determinants of ethanol, acetone, 2-propanol, d-limonene, α-pinene, and chloroform exposures. Hierarchical cluster analysis was conducted to partition workers into groups with similar cleaning task/product-use profiles. Linear mixed-effect regression models using log-transformed VOC measurements were applied to evaluate the association of individual VOCs with clusters of task/product use, industrial hygienists' grouping (IH) of tasks, grouping of product application, chemical ingredients of the cleaning products used, amount of product use, and ventilation. Results Cluster analysis identified eight task/product-use clusters that were distributed across multiple occupations and hospital units, with the exception of clusters consisting of housekeepers and floor strippers/waxers. Results of the mixed-effect models showed significant associations between selected VOC exposures and several clusters, combinations of IH-generated task groups and chemical ingredients, and product application groups. The patient/personal cleaning task using products containing chlorine was associated with elevated levels of personal chloroform and α-pinene exposures. Tasks associated with instrument sterilizing and disinfecting were significantly associated with personal d-limonene and 2-propanol exposures. Surface and floor cleaning and stripping tasks were predominated by housekeepers and floor strippers/waxers, and use of chlorine-, alcohol-, ethanolamine-, and quaternary ammonium compounds-based products was associated with exposures to chloroform, α-pinene, acetone, 2-propanol, or d-limonene. Conclusions Healthcare workers are exposed to a variety of chemicals that vary with tasks and ingredients of products used during cleaning and disinfecting. The combination of product ingredients with cleaning and disinfecting tasks were associated with specific VOCs. Exposure modules for questionnaires used in epidemiologic studies might benefit from seeking information on products used within a task context.
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Affiliation(s)
- Feng-Chiao Su
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Morgantown, WV, USA
| | - Melissa C Friesen
- Occupational and Environmental Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Aleksandr B Stefaniak
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Morgantown, WV, USA
| | - Paul K Henneberger
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Morgantown, WV, USA
| | - Ryan F LeBouf
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Morgantown, WV, USA
| | - Marcia L Stanton
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Morgantown, WV, USA
| | - Xiaoming Liang
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Morgantown, WV, USA
| | - Michael Humann
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Morgantown, WV, USA
| | - M Abbas Virji
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Morgantown, WV, USA
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Lovén K, Isaxon C, Wierzbicka A, Gudmundsson A. Characterization of airborne particles from cleaning sprays and their corresponding respiratory deposition fractions. JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 2019; 16:656-667. [PMID: 31361572 DOI: 10.1080/15459624.2019.1643466] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Cleaning workers are exposed to many risk factors, including handling of cleaning products. Epidemiological studies show that they have a high incidence of asthma and other respiratory symptoms. Some studies have indicated an even higher incidence of asthma in individuals using cleaning sprays regularly. It is known that sprays produce an aerosol that can expose the respiratory system to chemicals. Knowledge of the physical characteristics of the airborne particles, as well as the characteristics of the gas phase, is needed to determine how they affect the respiratory tract and why they cause airway symptoms. The aim of this study was to characterize the aerosols from seven different ready-to-use trigger cleaning sprays in terms of total airborne mass fraction, particle size distribution, and new particle formation from ozone reactions. An additional aim was to calculate the respiratory deposition fraction of the measured particles. The total airborne mass fraction was determined by comparing the mass deposited on the chamber wall with the mass emitted from the bottle during spraying. Particle number concentration and size distribution of the airborne particles were measured using an aerodynamic particle sizer and a fast aerosol mobility size spectrometer. The total airborne mass fraction was between 2.7% and 32.2% of the mass emitted from the bottle, depending on the product. Between 0.0001% and 0.01% of the total airborne mass fraction consisted of residual particles. However, these particles had a mass median aerodynamic diameter between 1.9 µm and 3.7 µm, constituting a total respiratory deposition of up to 77%. New particle formation in the presence of ozone was also shown to vary between 5,000 cm-3 and 35,000 cm-3 depending on the product, in the studied settings. These findings confirm that a substantial part (up to 1/3) of the mass sprayed from the bottle does not reach the intended surface. Thus, the use of cleaning sprays can result in chemical airway exposure, with particles in the relevant size range for both nasal and alveolar deposition.
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Affiliation(s)
- Karin Lovén
- Ergonomics and Aerosol Technology, Department of Design Sciences, Lund University , Lund , Sweden
| | - Christina Isaxon
- Ergonomics and Aerosol Technology, Department of Design Sciences, Lund University , Lund , Sweden
| | - Aneta Wierzbicka
- Ergonomics and Aerosol Technology, Department of Design Sciences, Lund University , Lund , Sweden
| | - Anders Gudmundsson
- Ergonomics and Aerosol Technology, Department of Design Sciences, Lund University , Lund , Sweden
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Anderson SE, Weatherly L, Shane HL. Contribution of antimicrobials to the development of allergic disease. Curr Opin Immunol 2019; 60:91-95. [PMID: 31185370 DOI: 10.1016/j.coi.2019.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 05/07/2019] [Indexed: 12/26/2022]
Abstract
Antimicrobials represent a broad class of chemicals with the intended purpose of eliminating or controlling the growth of harmful microorganisms. Exposure can occur occupationally or through the use or consumption of consumer products. The use of antimicrobial agents has been associated with an increased incidence of allergic diseases, including asthma, atopic dermatitis, and less commonly, anaphylaxis. Very diverse immunological mechanisms and mediators have been identified in the sensitization response to antimicrobial chemicals and the importance of the local microenviroment in the response is increasingly being recognized. A complete understanding of the mechanisms of allergic diseases resulting from antimicrobial exposure will help to ensure safe environments and exposure limits.
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Affiliation(s)
- Stacey E Anderson
- National Institute of Occupational Safety and Health, Health Effects Laboratory Division, Allergy and Clinical Immunology Branch, Morgantown, WV, 26508, United States.
| | - Lisa Weatherly
- National Institute of Occupational Safety and Health, Health Effects Laboratory Division, Allergy and Clinical Immunology Branch, Morgantown, WV, 26508, United States
| | - Hillary L Shane
- National Institute of Occupational Safety and Health, Health Effects Laboratory Division, Allergy and Clinical Immunology Branch, Morgantown, WV, 26508, United States
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Quaternary Ammonium Compounds: Simple in Structure, Complex in Application. Top Curr Chem (Cham) 2019; 377:14. [PMID: 31062103 DOI: 10.1007/s41061-019-0239-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 04/25/2019] [Indexed: 10/26/2022]
Abstract
Quaternary ammonium compounds, referred to as QACs, are cationic substances with a structure on the edge of organic and inorganic chemistry and unique physicochemical properties. The purpose of the present work is to introduce QACs and their wide application potential. Fundamental properties, methods of preparation, and utilization in organic synthesis are reviewed. Modern applications and the use of QACs as reactive substrates, reagents, phase-transfer catalysts, ionic liquids, electrolytes, frameworks, surfactants, herbicides, and antimicrobials are further covered. A brief discussion of the health and environmental impact of QACs is also provided. The emphasis is largely on tetraalkylammonium compounds bearing linear alkyl chains.
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Chen KH, Chung KM, Chung JH, Chen KT. Asthma associated with denatonium benzoate in a healthcare worker in Taiwan: A case report. Medicine (Baltimore) 2019; 98:e15818. [PMID: 31124982 PMCID: PMC6571374 DOI: 10.1097/md.0000000000015818] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Denatonium benzoate is a useful indicator to ensure that the respirator being used by an individual forms a tight enough seal to adequately protect against unwanted airborne exposure. Although the relative risk for adverse effects of fit testing using denatonium benzoate is low, the absolute number of workers with adverse reactions may nevertheless be sizeable. PATIENT CONCERNS A 34-year-old female nurse rapidly developed shortness of breath, cough, and agitation after denatonium benzoate fit testing. She had a history of allergy to shrimp, crab, mite, and disinfecting products (containing quaternary ammonium). DIAGNOSES Due to typical symptoms of asthma after exposure to denatonium benzoate aerosol without any other apparent cause, serial pulmonary function tests indicating obstructive lung function and a higher concentration of immunoglobulin antibody E, she was diagnosed with allergic asthma. INTERVENTIONS This patient was treated with omalizumab (Xolair), corticosteroid, β2 agonist, montelukast, and Symbicort turbuhaler. OUTCOMES The patient showed quick responses after treatment with diphenhydramine (intramuscularly), fenoterol HBr (inhalation), and prednisolone (oral). Approximately 2 weeks later, she suffered from difficulty breathing and asthmatic symptoms again when she was exposed to polished wax and disinfectant. She was treated with omalizumab (Xolair), corticosteroid, β2 agonist, montelukast, and Symbicort turbuhaler. The patient was in stable condition with improvement in symptoms during follow-up. LESSONS There may be potentially important health risks when healthcare workers are exposed to denatonium benzoate. Individuals who have a history of allergy to disinfecting products (containing quaternary ammonium) should avoid exposure of denatonium benzoate. More advanced research is needed in the future.
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Affiliation(s)
- Kou-Huang Chen
- School of Mechanical and Electrical Engineering, Sanming University, Sanming, Fujian Province, China
| | - Kuo-Mou Chung
- Division of Chest, Department of Internal Medicine
- Superintendent Office
| | | | - Kow-Tong Chen
- Department of Occupational Medicine, Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation)
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Whitworth KW, Berumen-Flucker B, Delclos GL, Fragoso S, Mata C, de Porras DGR. Job hazards and respiratory symptoms in Hispanic female domestic cleaners. ARCHIVES OF ENVIRONMENTAL & OCCUPATIONAL HEALTH 2019; 75:70-74. [PMID: 31033410 PMCID: PMC8849900 DOI: 10.1080/19338244.2019.1606774] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The occupational hazards and respiratory symptoms of domestic cleaners in USA are largely unknown. We conducted a cross-sectional study among 56 Hispanic female domestic cleaner on their health status and frequency of cleaning products used and tasks performed. While women used multi-use products (60.0%) and toilet bowl cleaners (51.8%) most days of the week, many (39.3%) reported not using personal protective equipment while cleaning. Itchy/watery eyes (61.8%) and itchy nose (56.4%) were the most frequently reported symptoms. A history of physician-diagnosed asthma was reported by 14.3% while 33.9% had symptoms of bronchial hyperresponsiveness (BHR). In conclusion, this vulnerable population has high prevalence of physician-diagnosis asthma and BHR symptoms and is potentially exposed to myriad occupational hazards. Further research exploring associations between products use, cleaning tasks and respiratory symptoms is warranted.
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Affiliation(s)
- Kristina W. Whitworth
- Department of Epidemiology, Human Genetics & Environmental Sciences, The University of Texas Health Science Center at Houston, School of Public Health in San Antonio, San Antonio, TX, USA
- Southwest Center for Occupational and Environmental Health (SWCOEH), The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Brenda Berumen-Flucker
- Department of Epidemiology, Human Genetics & Environmental Sciences, The University of Texas Health Science Center at Houston, School of Public Health in San Antonio, San Antonio, TX, USA
| | - George L. Delclos
- Department of Epidemiology, Human Genetics & Environmental Sciences, The University of Texas Health Science Center at Houston, School of Public Health, Houston, TX, USA
- Center for Research in Occupational Health (CiSAL), Universitat Pompeu Fabra, Barcelona, Spain
- CIBER of Epidemiology and Public Health, Madrid, Spain
- Institution at which the work was performed: The University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
| | - Sonia Fragoso
- Department of Epidemiology, Human Genetics & Environmental Sciences, The University of Texas Health Science Center at Houston, School of Public Health in San Antonio, San Antonio, TX, USA
| | - Claudia Mata
- Department of Epidemiology, Human Genetics & Environmental Sciences, The University of Texas Health Science Center at Houston, School of Public Health in San Antonio, San Antonio, TX, USA
| | - David Gimeno Ruiz de Porras
- Department of Epidemiology, Human Genetics & Environmental Sciences, The University of Texas Health Science Center at Houston, School of Public Health in San Antonio, San Antonio, TX, USA
- Southwest Center for Occupational and Environmental Health (SWCOEH), The University of Texas Health Science Center at Houston, Houston, TX, USA
- Center for Research in Occupational Health (CiSAL), Universitat Pompeu Fabra, Barcelona, Spain
- CIBER of Epidemiology and Public Health, Madrid, Spain
- Institution at which the work was performed: The University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
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Su FC, Friesen MC, Humann M, Stefaniak AB, Stanton ML, Liang X, LeBouf RF, Henneberger PK, Virji MA. Clustering asthma symptoms and cleaning and disinfecting activities and evaluating their associations among healthcare workers. Int J Hyg Environ Health 2019; 222:873-883. [PMID: 31010790 DOI: 10.1016/j.ijheh.2019.04.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 03/28/2019] [Accepted: 04/11/2019] [Indexed: 01/09/2023]
Abstract
Asthma is a heterogeneous disease with varying severity and subtypes. Recent reviews of epidemiologic studies have identified cleaning and disinfecting activities (CDAs) as important risk factors for asthma-related outcomes among healthcare workers. However, the complexity of CDAs in healthcare settings has rarely been examined. This study utilized a complex survey dataset and data reduction approaches to identify and group healthcare workers with similar patterns of asthma symptoms, and then explored their associations with groups of participants with similar patterns of CDAs. Self-reported information on asthma symptoms/care, CDAs, demographics, smoking status, allergic status, and other characteristics were collected from 2030 healthcare workers within nine selected occupations in New York City. Hierarchical clustering was conducted to systematically group participants based on similarity of patterns of the 27 asthma symptom/care variables, and 14 product applications during CDAs, separately. Word clouds were used to visualize the complex information on the resulting clusters. The associations of asthma health clusters (HCs) with exposure clusters (ECs) were evaluated using multinomial logistic regression. Five HCs were identified (HC-1 to HC-5), labelled based on predominant features as: "no symptoms", "winter cough/phlegm", "mild asthma symptoms", "undiagnosed/untreated asthma", and "asthma attacks/exacerbations". For CDAs, five ECs were identified (EC-1 to EC-5), labelled as: "no products", "housekeeping/chlorine", "patient care", "general cleaning/laboratory", and "disinfection products". Using HC-1 and EC-1 as the reference groups, EC-2 was associated with HC-4 (odds ratio (OR) = 3.11, 95% confidence interval (95% CI) = 1.46-6.63) and HC-5 (OR = 2.71, 95% CI = 1.25-5.86). EC-3 was associated with HC-5 (OR = 2.34, 95% CI = 1.16-4.72). EC-4 was associated with HC-5 (OR = 2.35, 95% CI = 1.07-5.13). EC-5 was associated with HC-3 (OR = 1.81, 95% CI = 1.09-2.99) and HC-4 (OR = 3.42, 95% CI = 1.24-9.39). Various combinations of product applications like using alcohols, bleach, high-level disinfectants, and enzymes to disinfect instruments and clean surfaces captured by the ECs were identified as risk factors for the different asthma symptoms clusters, indicating that prevention efforts may require targeting multiple products. The associations of HCs with EC can be used to better inform prevention strategies and treatment options to avoid disease progression. This study demonstrated hierarchical clustering and word clouds were useful techniques for analyzing and visualizing a complex dataset with a large number of potentially correlated variables to generate practical information that can inform prevention activities.
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Affiliation(s)
- Feng-Chiao Su
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Morgantown, WV, USA
| | - Melissa C Friesen
- Occupational and Environmental Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Michael Humann
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Morgantown, WV, USA
| | - Aleksandr B Stefaniak
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Morgantown, WV, USA
| | - Marcia L Stanton
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Morgantown, WV, USA
| | - Xiaoming Liang
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Morgantown, WV, USA
| | - Ryan F LeBouf
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Morgantown, WV, USA
| | - Paul K Henneberger
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Morgantown, WV, USA
| | - M Abbas Virji
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Morgantown, WV, USA.
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Holm SM, Leonard V, Durrani T, Miller MD. Do we know how best to disinfect child care sites in the United States? A review of available disinfectant efficacy data and health risks of the major disinfectant classes. Am J Infect Control 2019; 47:82-91. [PMID: 30172610 DOI: 10.1016/j.ajic.2018.06.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 06/24/2018] [Accepted: 06/25/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Children in child care settings have a high infectious burden. They are frequently exposed to sanitizing and disinfecting agents, whose toxicities have not been studied in these settings. Current guidance on the preferred disinfection agents for child care is vague. METHODS This article combines 2 different sources of information: the Environmental Protection Agency registration data on the efficacy of hospital-grade disinfectants and a review of the research on the toxicities of the most common of these disinfectants to summarize information that could be used for more evidence-based early care and education disinfection regulations and guidelines. RESULTS Coverage of these organisms varied both between disinfectant classes (defined by active ingredient), as well as within classes. The 3 most common active ingredients in the database-quaternary ammonias, bleaches, and hydrogen peroxides-had 251, 63, and 31 products, respectively. Quaternary ammonias and bleaches are both known asthmagens, with the potential for toxic gas release when mixed. Quaternary ammonias may also cause reproductive toxicity. Disinfectant-grade peroxides have relatively low inhalational toxicity. CONCLUSIONS A clear rationale is needed to establish policies for determining preferable disinfection products for use in child care settings, based on efficacy against relevant pathogens, toxicity, ease of use, and cost. When other factors are equal, the use of peroxide-based disinfectant products is recommended to minimize inhalational toxicity.
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Abstract
Background: Cleaning and disinfecting agents are widely used in modern life, in homes, schools, public places, and workplaces as well as in recreational facilities such as swimming pools. Use has been for sanitizing purposes and to assist in reduction of infection as well as for deodorizing purposes. However, adverse respiratory effects have been associated with use of cleaning products ranging from effects in infancy and early childhood up to adults at home and work. Methods: This review summarizes recent published literature on the effects of cleaning agents used pre-natally, in childhood and adult life, at home, work, and in swimming pools. Results: Several studies have indicated that there is an increased risk of developing asthma among adults with frequent exposure to cleaning products at work and in the home. Potential mechanisms include sensitization and respiratory irritant effects. Exposure to irritant chlorine by-products from swimming pools have also been associated with respiratory effects and increased risk of asthma. Potential effects from maternal exposures to cleaning products on infants, and effects on early childhood atopy are less clear. Conclusions: Exposure to cleaning agents increases relative risks of asthma among workers, and adults using these agents in the home. Risks are also increased with exposure to chlorinated by-products from swimming pools, both in adults and children. Further studies are needed to understand the mechanisms of these associations.
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61
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Caridi MN, Humann MJ, Liang X, Su FC, Stefaniak AB, LeBouf RF, Stanton ML, Virji MA, Henneberger PK. Occupation and task as risk factors for asthma-related outcomes among healthcare workers in New York City. Int J Hyg Environ Health 2018; 222:211-220. [PMID: 30327176 DOI: 10.1016/j.ijheh.2018.10.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 08/23/2018] [Accepted: 10/04/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Previous studies have suggested an association of asthma onset and exacerbation with cleaning and disinfecting activities in a number of industries, including healthcare. The objective of the current study was to investigate the association of asthma and related outcomes with occupations and tasks in urban healthcare workers in the United States. METHODS A questionnaire was implemented in a sample of workers from nine healthcare occupations in New York City. We used regression models to examine the association of post-hire asthma, current asthma, exacerbation of asthma, a symptom algorithm for bronchial hyper-responsiveness (BHR-related symptoms), a symptom-based asthma score, and the symptom wheeze with occupation and four healthcare tasks, while adjusting for other risk factors and potential confounders. RESULTS A total of 2030 participants completed the questionnaire. The task of cleaning fixed surfaces was significantly associated with most outcome variables, including current asthma (odds ratio (OR) = 1.84, 95% confidence interval (CI) 1.26-2.68), moderate exacerbation (OR = 3.10, 95% CI 1.25-7.67), and BHR-related symptoms (OR = 1.38, 95% CI 1.08-1.77). In comparison to nursing assistants, the occupations environmental service workers and registered nurses were at higher risk for current asthma, and licensed practical nurses were at higher risk for moderate exacerbation. Other tasks associated with outcomes were administering aerosolized medications with current asthma and moderate exacerbation, and sterilizing medical equipment with BHR-related symptoms. CONCLUSIONS These findings add to the growing body of evidence for the association of asthma with cleaning and other activities in healthcare. Further research is especially needed to investigate the association of asthma-related outcomes with exposure metrics based on tasks, products, and chemical exposures in healthcare.
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Affiliation(s)
- Morgan N Caridi
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Morgantown, WV, United States
| | - Michael J Humann
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Morgantown, WV, United States
| | - Xiaoming Liang
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Morgantown, WV, United States
| | - Feng-Chiao Su
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Morgantown, WV, United States
| | - Aleksandr B Stefaniak
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Morgantown, WV, United States
| | - Ryan F LeBouf
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Morgantown, WV, United States
| | - Marcia L Stanton
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Morgantown, WV, United States
| | - M Abbas Virji
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Morgantown, WV, United States
| | - Paul K Henneberger
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Morgantown, WV, United States.
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62
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Hawley B, Casey M, Virji MA, Cummings KJ, Johnson A, Cox-Ganser J. Respiratory Symptoms in Hospital Cleaning Staff Exposed to a Product Containing Hydrogen Peroxide, Peracetic Acid, and Acetic Acid. Ann Work Expo Health 2018; 62:28-40. [PMID: 29077798 DOI: 10.1093/annweh/wxx087] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 10/02/2017] [Indexed: 11/13/2022] Open
Abstract
Cleaning and disinfecting products consisting of a mixture of hydrogen peroxide (HP), peracetic acid (PAA), and acetic acid (AA) are widely used as sporicidal agents in health care, childcare, agricultural, food service, and food production industries. HP and PAA are strong oxidants and their mixture is a recognized asthmagen. However, few exposure assessment studies to date have measured HP, PAA, and AA in a health care setting. In 2015, we performed a health and exposure assessment at a hospital where a new sporicidal product, consisting of HP, PAA, and AA was introduced 16 months prior. We collected 49 full-shift time-weighted average (TWA) air samples and analyzed samples for HP, AA, and PAA content. Study participants were observed while they performed cleaning duties, and duration and frequency of cleaning product use was recorded. Acute upper airway, eye, and lower airway symptoms were recorded in a post-shift survey (n = 50). A subset of 35 cleaning staff also completed an extended questionnaire that assessed symptoms reported by workers as regularly occurring or as having occurred in the previous 12 months. Air samples for HP (range: 5.5 to 511.4 ppb) and AA (range: 6.7 to 530.3 ppb) were all below established US occupational exposure limits (OEL). To date, no full-shift TWA OEL for PAA has been established in the United States, however an OEL of 0.2 ppm has been suggested by several research groups. Air samples for PAA ranged from 1.1 to 48.0 ppb and were well below the suggested OEL of 0.2 ppm. Hospital cleaning staff using a sporicidal product containing HP, PAA, and AA reported work-shift eye (44%), upper airway (58%), and lower airway (34%) symptoms. Acute nasal and eye irritation were significantly positively associated with increased exposure to the mixture of the two oxidants: HP and PAA, as well as the total mixture (TM)of HP, PAA, and AA. Shortness of breath when hurrying on level ground or walking up a slight hill was significantly associated with increased exposure to the oxidant mixture (P = 0.017), as well as the TM (P = 0.026). Our results suggest that exposure to a product containing HP, PAA, and AA contributed to eye and respiratory symptoms reported by hospital cleaning staff at low levels of measured exposure.
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Affiliation(s)
- Brie Hawley
- Respiratory Health Division, National Institute for Occupational Safety and Health, CDC, USA
| | - Megan Casey
- Respiratory Health Division, National Institute for Occupational Safety and Health, CDC, USA
| | - Mohammed Abbas Virji
- Respiratory Health Division, National Institute for Occupational Safety and Health, CDC, USA
| | - Kristin J Cummings
- Respiratory Health Division, National Institute for Occupational Safety and Health, CDC, USA
| | | | - Jean Cox-Ganser
- Respiratory Health Division, National Institute for Occupational Safety and Health, CDC, USA
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63
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An Official American Thoracic Society Workshop Report: Presentations and Discussion of the Sixth Jack Pepys Workshop on Asthma in the Workplace. Ann Am Thorac Soc 2018; 14:1361-1372. [PMID: 28862493 DOI: 10.1513/annalsats.201706-508st] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The Sixth Jack Pepys Workshop on Asthma in the Workplace focused on six key themes regarding the recognition and assessment of work-related asthma and airway diseases: (1) cleaning agents and disinfectants (including in swimming pools) as irritants and sensitizers: how to evaluate types of bronchial reactions and reduce risks; (2) population-based studies of occupational obstructive diseases: use of databanks, advantages and pitfalls, what strategies to deal with biases and confounding?; (3) damp environments, dilapidated buildings, recycling processes, and molds, an increasing problem: mechanisms, how to assess causality and diagnosis; (4) diagnosis of occupational asthma and rhinitis: how useful are recombinant allergens (component-resolved diagnosis), metabolomics, and other new tests?; (5) how does exposure to gas, dust, and fumes enhance sensitization and asthma?; and (6) how to determine probability of occupational causality in chronic obstructive pulmonary disease: epidemiological and clinical, confirmation, and compensation aspects. A summary of the presentations and discussion is provided in this proceedings document. Increased knowledge has been gained in each topic over the past few years, but there remain aspects of controversy and uncertainty requiring further research.
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64
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Quinot C, Amsellem-Dubourget S, Temam S, Sevin E, Barreto C, Tackin A, Félicité J, Lyon-Caen S, Siroux V, Girard R, Descatha A, Le Moual N, Dumas O. Development of a bar code-based exposure assessment method to evaluate occupational exposure to disinfectants and cleaning products: a pilot study. Occup Environ Med 2018; 75:668-674. [PMID: 29760172 DOI: 10.1136/oemed-2017-104793] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 02/27/2018] [Accepted: 04/21/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Healthcare workers are highly exposed to various types of disinfectants and cleaning products. Assessment of exposure to these products remains a challenge. We aimed to investigate the feasibility of a method, based on a smartphone application and bar codes, to improve occupational exposure assessment among hospital/cleaning workers in epidemiological studies. METHODS A database of disinfectants and cleaning products used in French hospitals, including their names, bar codes and composition, was developed using several sources: ProdHyBase (a database of disinfectants managed by hospital hygiene experts), and specific regulatory agencies and industrial websites. A smartphone application has been created to scan bar codes of products and fill a short questionnaire. The application was tested in a French hospital. The ease of use and the ability to record information through this new approach were estimated. RESULTS The method was tested in a French hospital (7 units, 14 participants). Through the application, 126 records (one record referred to one product entered by one participant/unit) were registered, majority of which were liquids (55.5%) or sprays (23.8%); 20.6% were used to clean surfaces and 15.9% to clean toilets. Workers used mostly products with alcohol and quaternary ammonium compounds (>90% with weekly use), followed by hypochlorite bleach and hydrogen peroxide (28.6%). For most records, information was available on the name (93.7%) and bar code (77.0%). Information on product compounds was available for all products and recorded in the database. CONCLUSION This innovative and easy-to-use method could help to improve the assessment of occupational exposure to disinfectants/cleaning products in epidemiological studies.
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Affiliation(s)
- Catherine Quinot
- INSERM, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, U1168, F-94807, Villejuif, France.,UVSQ, UMR-S 1168, University Versailles St-Quentin-en-Yvelines, F-78180, Montigny le Bretonneux, France
| | | | - Sofia Temam
- INSERM, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, U1168, F-94807, Villejuif, France.,UVSQ, UMR-S 1168, University Versailles St-Quentin-en-Yvelines, F-78180, Montigny le Bretonneux, France.,Faculty of Medicine, University Paris-Sud, Le Kremlin-Bicêtre, France
| | | | - Christine Barreto
- ProdHyBase, CClin Sud-Est, Saint-Genis-Laval, France.,ProdHyBase, Unit of Hygiene and Epidemiology, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Arzu Tackin
- AP-HP UVSQ, Equipe opérationnelle d'hygiène hospitalière, University Hospital of Poincaré, Garches, France
| | | | - Sarah Lyon-Caen
- INSERM, CNRS, Université Grenoble Alpes, U1209, Institute for Advanced Biosciences (IAB), Team of Environmental Epidemiology Applied to Reproduction and Respiratory Health, Grenoble (La Tronche), France
| | - Valérie Siroux
- INSERM, CNRS, Université Grenoble Alpes, U1209, Institute for Advanced Biosciences (IAB), Team of Environmental Epidemiology Applied to Reproduction and Respiratory Health, Grenoble (La Tronche), France
| | - Raphaële Girard
- ProdHyBase, Unit of Hygiene and Epidemiology, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Alexis Descatha
- INSERM, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, U1168, F-94807, Villejuif, France.,UVSQ, UMR-S 1168, University Versailles St-Quentin-en-Yvelines, F-78180, Montigny le Bretonneux, France.,AP-HP UVSQ, Occupational Health Unit/Population-Based Epidemiological Cohorts Unit, UMS 011, University Hospital of Poincaré, Garches, France
| | - Nicole Le Moual
- INSERM, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, U1168, F-94807, Villejuif, France.,UVSQ, UMR-S 1168, University Versailles St-Quentin-en-Yvelines, F-78180, Montigny le Bretonneux, France
| | - Orianne Dumas
- INSERM, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, U1168, F-94807, Villejuif, France.,UVSQ, UMR-S 1168, University Versailles St-Quentin-en-Yvelines, F-78180, Montigny le Bretonneux, France
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65
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Dumas O, Varraso R, Boggs KM, Descatha A, Henneberger PK, Quinot C, Speizer FE, Zock JP, Le Moual N, Camargo CA. Association of hand and arm disinfection with asthma control in US nurses. Occup Environ Med 2018; 75:378-381. [PMID: 29475850 PMCID: PMC5899017 DOI: 10.1136/oemed-2017-104740] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 01/23/2018] [Accepted: 02/04/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To investigate the association between occupational exposure to disinfectants/antiseptics used for hand hygiene and asthma control in nurses. METHODS In 2014, we invited female nurses with asthma drawn from the Nurses' Health Study II to complete two supplemental questionnaires on their occupation and asthma (cross-sectional study, response rate: 80%). Among 4055 nurses (mean age: 59 years) with physician-diagnosed asthma and asthma medication use in the past year, we examined asthma control, as defined by the Asthma Control Test (ACT). Nurses were asked about the daily frequency of hand hygiene tasks: 'wash/scrub hands with disinfectants/hand sanitizers' (hand hygiene) and 'wash/scrub arms with disinfecting products' (surrogate of surgical hand/arm antisepsis). Analyses were adjusted for age, race, ethnicity, smoking status and body mass index. RESULTS Nurses with partly controlled asthma (ACT: 20-24, 50%) and poorly controlled asthma (ACT ≤19, 18%) were compared with nurses with controlled asthma (ACT=25, 32%). In separate models, both hand and arm hygiene were associated with poorly controlled asthma. After mutual adjustment, only arm hygiene was associated with poorly controlled asthma: OR (95% CI) for <1 time/day, 1.38 (1.06 to 1.80); ≥1 time/day, 1.96 (1.52 to 2.51), versus never. We observed a consistent dose-response relationship between frequency of arm hygiene tasks (never to >10 times/day) and poor asthma control. Associations persisted after further adjustment for surfaces/instruments disinfection tasks. CONCLUSIONS Frequency of hand/arm hygiene tasks in nurses was associated with poor asthma control. The results suggest an adverse effect of products used for surgical hand/arm antisepsis. This potential new occupational risk factor for asthma warrants further study.
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Affiliation(s)
- Orianne Dumas
- INSERM, U1168, VIMA: Aging and chronic diseases. Epidemiological and public health approaches, F-94807, Villejuif, France
- Univ Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
| | - Raphaëlle Varraso
- INSERM, U1168, VIMA: Aging and chronic diseases. Epidemiological and public health approaches, F-94807, Villejuif, France
- Univ Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
| | - Krislyn M Boggs
- Channing Division of Network Medicine, Department of Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Alexis Descatha
- INSERM, U1168, VIMA: Aging and chronic diseases. Epidemiological and public health approaches, F-94807, Villejuif, France
- Univ Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
- AP-HP UVSQ, Occupational Health Unit/Population-Based Epidemiological Cohorts Unit, UMS 011, University Hospital of Poincaré, Garches, France
| | - Paul K Henneberger
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, WV, USA
| | - Catherine Quinot
- INSERM, U1168, VIMA: Aging and chronic diseases. Epidemiological and public health approaches, F-94807, Villejuif, France
- Univ Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
| | - Frank E Speizer
- Channing Division of Network Medicine, Department of Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jan-Paul Zock
- ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Nicole Le Moual
- INSERM, U1168, VIMA: Aging and chronic diseases. Epidemiological and public health approaches, F-94807, Villejuif, France
- Univ Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
| | - Carlos A Camargo
- Channing Division of Network Medicine, Department of Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, USA
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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66
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Pacheco KA. Occupational dermatitis: How to identify the exposures, make the diagnosis, and treat the disease. Ann Allergy Asthma Immunol 2018; 120:583-591. [PMID: 29698693 DOI: 10.1016/j.anai.2018.04.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 04/11/2018] [Accepted: 04/13/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Karin A Pacheco
- Division of Environmental & Occupational Health Sciences, National Jewish Health, Denver, Colorado.
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67
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Ederle C, Donnay C, Khayath N, Mielcarek M, de Blay F. Asthma and Cleaning: What’s New? CURRENT TREATMENT OPTIONS IN ALLERGY 2018. [DOI: 10.1007/s40521-018-0153-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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68
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Back to Basics: Environmental Cleaning Hazards. AORN J 2017; 106:424-432. [DOI: 10.1016/j.aorn.2017.08.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 08/25/2017] [Indexed: 11/20/2022]
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69
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Heederik D. Occupational exposure and asthma control. Eur Respir J 2017; 50:50/4/1701951. [PMID: 29074549 DOI: 10.1183/13993003.01951-2017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 09/26/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Dick Heederik
- Institute for Risk Assessment Sciences, Utrecht University, Utrecht, The Netherlands
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70
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Dumas O, Wiley AS, Quinot C, Varraso R, Zock JP, Henneberger PK, Speizer FE, Le Moual N, Camargo CA. Occupational exposure to disinfectants and asthma control in US nurses. Eur Respir J 2017; 50:50/4/1700237. [PMID: 28982772 DOI: 10.1183/13993003.00237-2017] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 07/15/2017] [Indexed: 11/05/2022]
Abstract
Disinfectant use has been associated with adverse respiratory effects among healthcare workers. However, the specific harmful agents have not been elucidated. We examined the association between occupational exposure to disinfectants and asthma control in the Nurses' Health Study II, a large cohort of female nurses.Nurses with asthma were invited in 2014 to complete two questionnaires on their current occupation and asthma (response rate 80%). Asthma control was defined by the Asthma Control Test (ACT). Exposure to major disinfectants was evaluated by a job-task-exposure matrix (JTEM).Analyses included 4102 nurses with asthma (mean age 58 years). Asthma control was poor (ACT score 16-19) in 12% of nurses and very poor (ACT score ≤15) in 6% of nurses. Use of disinfectants to clean medical instruments (19% exposed) was associated with poorly (OR 1.37; 95% CI 1.05-1.79) and very poorly (OR 1.88, 95% CI 1.38-2.56) controlled asthma (ptrend=0.004, after adjustment for potential confounders). Using JTEM estimates, exposure to formaldehyde, glutaraldehyde, hypochlorite bleach, hydrogen peroxide and enzymatic cleaners was associated with poor asthma control (all ptrend<0.05); exposure to quaternary ammonium compounds and alcohol was not.Use of several disinfectants was associated with poor asthma control. Our findings suggest targets for future efforts to prevent worsening of asthma control in healthcare workers.
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Affiliation(s)
- Orianne Dumas
- INSERM U1168, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, Villejuif, France .,Université Versailles St-Quentin-en-Yvelines, UMRS 1168, Montigny le Bretonneux, France
| | - Aleta S Wiley
- Channing Division of Network Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Catherine Quinot
- INSERM U1168, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, Villejuif, France.,Université Versailles St-Quentin-en-Yvelines, UMRS 1168, Montigny le Bretonneux, France
| | - Raphaëlle Varraso
- INSERM U1168, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, Villejuif, France.,Université Versailles St-Quentin-en-Yvelines, UMRS 1168, Montigny le Bretonneux, France
| | - Jan-Paul Zock
- ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain.,Universitat Pompeu Fabra (UPF), Barcelona, Spain.,CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Paul K Henneberger
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, WV, USA
| | - Frank E Speizer
- Channing Division of Network Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Nicole Le Moual
- INSERM U1168, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, Villejuif, France.,Université Versailles St-Quentin-en-Yvelines, UMRS 1168, Montigny le Bretonneux, France
| | - Carlos A Camargo
- Channing Division of Network Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Dept of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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71
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Abstract
PURPOSE OF REVIEW Asthma due to cleaning products has been known for 20 years, and the interest in this topic is still large because of the number of cleaning workers with respiratory problems. In this review, we sought to highlight the most recent findings on the relationship between exposure to cleaning products and asthma and to summarize the specific literature published between 2013 and 2016. RECENT FINDINGS Women are confirmed as most of workers exposed to cleaning products and have a higher frequency than men of work-related respiratory symptoms and diseases. Many cases of asthma due to cleaning products occur in healthcare occupations. The increased risk of asthma has been shown to be related to the number of years in the job and to early life disadvantage. Recent evidence suggests that predisposition to adult-onset asthma may be related to interaction between genes and occupational exposure to low-molecular weight agents/irritants. There is some evidence that an irritant mechanism is more common, although several case reports showed animmunologic mechanism (e.g. disinfectants, amine compounds, aldehydes and fragrances). SUMMARY The review updated recent findings on epidemiology, cleaning agents and their mechanism, and prevention of asthma due to cleaning agents. This article provides new information on the level of exposure, which is still high in professional cleaners and even more in domestic cleaners, and on the frequency of asthma in professional and domestic cleaners. An irritant mechanism is more common, although an immunological mechanism is possible, especially in healthcare workers exposed to disinfectants.
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72
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Vincent MJ, Parker A, Maier A. Cleaning and asthma: A systematic review and approach for effective safety assessment. Regul Toxicol Pharmacol 2017; 90:231-243. [PMID: 28918194 DOI: 10.1016/j.yrtph.2017.09.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 07/06/2017] [Accepted: 09/10/2017] [Indexed: 12/14/2022]
Abstract
Research indicates a correlative relationship between asthma and use of consumer cleaning products. We conduct a systematic review of epidemiological literature on persons who use or are exposed to cleaning products, both in occupational and domestic settings, and risk of asthma or asthma-like symptoms to improve understanding of the causal relationship between exposure and asthma. A scoring method for assessing study reliability is presented. Although research indicates an association between asthma and the use of cleaning products, no study robustly investigates exposure to cleaning products or ingredients along with asthma risk. This limits determination of causal relationships between asthma and specific products or ingredients in chemical safety assessment. These limitations, and a lack of robust animal models for toxicological assessment of asthma, create the need for a weight-of-evidence (WoE) approach to examine an ingredient or product's asthmatic potential. This proposed WoE method organizes diverse lines of data (i.e., asthma, sensitization, and irritation information) through a systematic, hierarchical framework that provides qualitatively categorized conclusions using hazard bands to predict a specific product or ingredient's potential for asthma induction. This work provides a method for prioritizing chemicals as a first step for quantitative and scenario-specific safety assessments based on their potential for inducing asthmatic effects. Acetic acid is used as a case study to test this framework.
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Affiliation(s)
- Melissa J Vincent
- Department Environmental Health, University Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Ann Parker
- Department Environmental Health, University Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew Maier
- Department Environmental Health, University Cincinnati College of Medicine, Cincinnati, OH, USA
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73
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Abstract
Healthcare workers (HCWs) are exposed to a range of high and low molecular weight agents that are allergic sensitizers or irritants including cleaners and disinfectants, natural rubber latex, and various medications. Studies have shown that exposed HCWs are at risk for work-related rhinitis and asthma (WRA). Work-related rhinitis may precede development of WRA and should be considered as an early marker of WRA. Avoidance of causative exposures through control strategies such as elimination, substitution, engineering controls, and process modification is the preferred primary prevention strategy for preventing development of work-related allergic diseases. There is limited evidence for the effectiveness of respirators in preventing occupational asthma. If sensitizer-induced WRA is diagnosed, it is important to avoid further exposure to the causative agent, preferably by more rigorous application of exposure control strategies to the workplace. This review focuses on allergic occupational respiratory diseases in HCWs.
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74
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LeBouf RF, Virji MA, Ranpara A, Stefaniak AB. Air and Surface Sampling Method for Assessing Exposures to Quaternary Ammonium Compounds Using Liquid Chromatography Tandem Mass Spectrometry. Ann Work Expo Health 2017; 61:724-736. [PMID: 28927165 PMCID: PMC5826613 DOI: 10.1093/annweh/wxx037] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 05/11/2017] [Indexed: 11/13/2022] Open
Abstract
This method was designed for sampling select quaternary ammonium (quat) compounds in air or on surfaces followed by analysis using ultraperformance liquid chromatography tandem mass spectrometry. Target quats were benzethonium chloride, didecyldimethylammonium bromide, benzyldimethyldodecylammonium chloride, benzyldimethyltetradecylammonium chloride, and benzyldimethylhexadecylammonium chloride. For air sampling, polytetrafluoroethylene (PTFE) filters are recommended for 15-min to 24-hour sampling. For surface sampling, Pro-wipe® 880 (PW) media was chosen. Samples were extracted in 60:40 acetonitrile:0.1% formic acid for 1 hour on an orbital shaker. Method detection limits range from 0.3 to 2 ng/ml depending on media and analyte. Matrix effects of media are minimized through the use of multiple reaction monitoring versus selected ion recording. Upper confidence limits on accuracy meet the National Institute for Occupational Safety and Health 25% criterion for PTFE and PW media for all analytes. Using PTFE and PW analyzed with multiple reaction monitoring, the method quantifies levels among the different quats compounds with high precision (<10% relative standard deviation) and low bias (<11%). The method is sensitive enough with very low method detection limits to capture quats on air sampling filters with only a 15-min sample duration with a maximum assessed storage time of 103 days before sample extraction. This method will support future exposure assessment and quantitative epidemiologic studies to explore exposure-response relationships and establish levels of quats exposures associated with adverse health effects.
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Affiliation(s)
- Ryan F. LeBouf
- Field Studies Branch, Respiratory Health Division, National Institute for Occupational Safety and Health, 1095 Willowdale Road, Morgantown, WV 26505, USA
| | - Mohammed Abbas Virji
- Field Studies Branch, Respiratory Health Division, National Institute for Occupational Safety and Health, 1095 Willowdale Road, Morgantown, WV 26505, USA
| | - Anand Ranpara
- Field Studies Branch, Respiratory Health Division, National Institute for Occupational Safety and Health, 1095 Willowdale Road, Morgantown, WV 26505, USA
| | - Aleksandr B. Stefaniak
- Field Studies Branch, Respiratory Health Division, National Institute for Occupational Safety and Health, 1095 Willowdale Road, Morgantown, WV 26505, USA
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Dumas O, Wiley AS, Henneberger PK, Speizer FE, Zock JP, Varraso R, Le Moual N, Boggs KM, Camargo CA. Determinants of disinfectant use among nurses in U.S. healthcare facilities. Am J Ind Med 2017; 60:131-140. [PMID: 27862135 DOI: 10.1002/ajim.22671] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND Disinfectant use among healthcare workers has been associated with respiratory disorders, especially asthma. We aimed to describe disinfectants used by U.S. nurses, and to investigate qualitative and quantitative differences according to workplace characteristics and region. METHODS Disinfectant use was assessed by questionnaire in 8,851 nurses. Hospital characteristics were obtained from the American Hospital Association database. RESULTS Working in a hospital was associated with higher disinfectant use (OR: 2.06 [95%CI: 1.89-2.24]), but lower spray use (0.74 [0.66-0.82]). Nurses working in smaller hospitals (<50 beds vs. ≥200 beds) were more likely to use disinfectants (1.69 [1.23-2.32]) and sprays (1.69 [1.20-2.38]). Spray use was lower in the West than in the Northeast (0.75 [0.58-0.97]). CONCLUSION Disinfectant use was more common among nurses working in smaller hospitals, possibly because they perform more diverse tasks. Variations in spray use by hospital size and region suggest additional targets for future efforts to prevent occupational asthma. Am. J. Ind. Med. 60:131-140, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Orianne Dumas
- INSERM, VIMA: Aging and Chronic Diseases; Epidemiological and Public Health Approaches; Villejuif France
- Univ Versailles St-Quentin-en-Yvelines; Montigny le Bretonneux France
| | - Aleta S. Wiley
- Channing Division of Network Medicine; Department of Medicine; Brigham and Women's Hospital and Harvard Medical School; Boston Massachusetts
| | - Paul K. Henneberger
- Respiratory Health Division National Institute for Occupational Safety and Health; Morgantown West Virginia
| | - Frank E. Speizer
- Channing Division of Network Medicine; Department of Medicine; Brigham and Women's Hospital and Harvard Medical School; Boston Massachusetts
| | - Jan-Paul Zock
- ISGlobal; Centre for Research in Environmental Epidemiology (CREAL); Barcelona Spain
- Universitat Pompeu Fabra (UPF); Barcelona Spain
- CIBER Epidemiología y Salud Pública (CIBERESP); Madrid Spain
| | - Raphaëlle Varraso
- INSERM, VIMA: Aging and Chronic Diseases; Epidemiological and Public Health Approaches; Villejuif France
- Univ Versailles St-Quentin-en-Yvelines; Montigny le Bretonneux France
| | - Nicole Le Moual
- INSERM, VIMA: Aging and Chronic Diseases; Epidemiological and Public Health Approaches; Villejuif France
- Univ Versailles St-Quentin-en-Yvelines; Montigny le Bretonneux France
| | - Krislyn M. Boggs
- Channing Division of Network Medicine; Department of Medicine; Brigham and Women's Hospital and Harvard Medical School; Boston Massachusetts
| | - Carlos A. Camargo
- Channing Division of Network Medicine; Department of Medicine; Brigham and Women's Hospital and Harvard Medical School; Boston Massachusetts
- Department of Emergency Medicine; Massachusetts General Hospital and Harvard Medical School; Boston Massachusetts
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76
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Abstract
PURPOSE OF REVIEW The present review summarizes the recent literature on the relation between chronic workplace irritant exposures and asthma, focusing on exposures of low to moderate levels. We discuss results from epidemiological surveys, potential biological mechanisms, and needs for further research. These aspects are largely illustrated by studies on exposure to cleaning products. RECENT FINDINGS Recent results from nine population-based and workplace-based epidemiological studies, mostly cross-sectional, found an increased risk of both new-onset and work-exacerbated asthma among participants exposed to moderate level of irritants and/or cleaning products. SUMMARY Evidence of a causal effect of chronic workplace irritant exposure in new-onset asthma remains limited, mainly because of a lack of longitudinal studies and the difficulty to evaluate irritant exposures. However, recent epidemiological studies strengthen the evidence of an effect of chronic exposure to irritants in work-related asthma. The underlying mechanism remains unknown but may be related to oxidative stress, neurogenic inflammation and dual irritant and adjuvant effects. However, disentangling chronic irritant effects from either acute irritant-induced asthma or immunological low molecular weight agent-induced asthma is difficult for some agents. Further research is needed to improve assessment of irritant exposures and identify biomarkers.
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77
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Quinot C, Dumas O, Henneberger PK, Varraso R, Wiley AS, Speizer FE, Goldberg M, Zock JP, Camargo CA, Le Moual N. Development of a job-task-exposure matrix to assess occupational exposure to disinfectants among US nurses. Occup Environ Med 2016; 74:130-137. [PMID: 27566782 DOI: 10.1136/oemed-2016-103606] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 06/29/2016] [Accepted: 08/02/2016] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Occupational exposure to disinfectants is associated with work-related asthma, especially in healthcare workers. However, little is known about the specific products involved. To evaluate disinfectant exposures, we designed job-exposure (JEM) and job-task-exposure (JTEM) matrices, which are thought to be less prone to differential misclassification bias than self-reported exposure. We then compared the three assessment methods: self-reported exposure, JEM and JTEM. METHODS Disinfectant use was assessed by an occupational questionnaire in 9073 US female registered nurses without asthma, aged 49-68 years, drawn from the Nurses' Health Study II. A JEM was created based on self-reported frequency of use (1-3, 4-7 days/week) of 7 disinfectants and sprays in 8 nursing jobs. We then created a JTEM combining jobs and disinfection tasks to further reduce misclassification. Exposure was evaluated in 3 classes (low, medium, high) using product-specific cut-offs (eg, <30%, 30-49.9%, ≥50%, respectively, for alcohol); the cut-offs were defined from the distribution of self-reported exposure per job/task. RESULTS The most frequently reported disinfectants were alcohol (weekly use: 39%), bleach (22%) and sprays (20%). More nurses were classified as highly exposed by JTEM (alcohol 41%, sprays 41%, bleach 34%) than by JEM (21%, 30%, 26%, respectively). Agreement between JEM and JTEM was fair-to-moderate (κ 0.3-0.5) for most disinfectants. JEM and JTEM exposure estimates were heterogeneous in most nursing jobs, except in emergency room and education/administration. CONCLUSIONS The JTEM may provide more accurate estimates than the JEM, especially for nursing jobs with heterogeneous tasks. Use of the JTEM is likely to reduce exposure misclassification.
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Affiliation(s)
- C Quinot
- INSERM, U1168, VIMA: Aging and Chronic Diseases. Epidemiological and Public Health Approaches, F-94807, Villejuif, France.,Univ Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
| | - O Dumas
- INSERM, U1168, VIMA: Aging and Chronic Diseases. Epidemiological and Public Health Approaches, F-94807, Villejuif, France.,Univ Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France.,Channing Division of Network Medicine, Department of Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - P K Henneberger
- Division of Respiratory Disease Studies, National Institute for Occupational Safety and Health, Morgantown, West Virginia, USA
| | - R Varraso
- INSERM, U1168, VIMA: Aging and Chronic Diseases. Epidemiological and Public Health Approaches, F-94807, Villejuif, France.,Univ Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
| | - A S Wiley
- Channing Division of Network Medicine, Department of Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - F E Speizer
- Channing Division of Network Medicine, Department of Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - M Goldberg
- INSERM, U1168, VIMA: Aging and Chronic Diseases. Epidemiological and Public Health Approaches, F-94807, Villejuif, France.,Univ Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France.,INSERM-UVSQ, UMS 011, Villejuif, France
| | - J P Zock
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands.,ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain.,Universitat Pompeu Fabra (UPF), Barcelona, Spain.,CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - C A Camargo
- Channing Division of Network Medicine, Department of Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - N Le Moual
- INSERM, U1168, VIMA: Aging and Chronic Diseases. Epidemiological and Public Health Approaches, F-94807, Villejuif, France.,Univ Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
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78
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Hales BJ, Hizawa N, Jenmalm M, Sverremark-Ekström E, Wardlaw AJ. Developments in the field of allergy in 2014 through the eyes of Clinical and Experimental Allergy. Clin Exp Allergy 2016; 45:1723-45. [PMID: 26492197 DOI: 10.1111/cea.12663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The pathogenesis of asthma continues to be a major topic of interest to our authors with reviews and original papers on the role of viruses, mechanisms of inflammation, biomarkers, and phenotypes of asthma being major topics. A number of papers described new treatments for asthma focusing on blocking the Th2 response reflecting the fact that two decades of work in this area is finally bearing fruit. The pathogenesis of chronic rhinosinusitis is a growing area of interest, but there has been less on the genetics of airways disease than in previous years possibly reflecting the degree of rigour (and therefore a smaller body of work), with which these sorts of studies are now being undertaken. There continues to be a wide range of papers dealing with mechanisms of allergic disease ranging from clinical-based studies to basic research and the use of in vivo animal models especially mice. As before, mechanisms and new approaches to immunotherapy are common themes. Several were published in the allergens section investigating modification of allergens to increase their effectiveness and reduce the risk of adverse events. Risk factors for allergic disease was a common theme in the epidemiology section and food allergy a common theme in clinical allergy with papers on the development of protocols to induce tolerance and attempts to find biomarkers to distinguish sensitization from allergic disease. This was another exciting year for the editors, and we hope the readers of the journal.
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Affiliation(s)
- B J Hales
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
| | - N Hizawa
- Department of Pulmonary Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - M Jenmalm
- Unit of Autoimmunity and Immune Regulation, Division of Clinical Immunology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - E Sverremark-Ekström
- M.C., Department of Molecular Biosciences, The Wenner-Gren Institute, Stockholm University, Stockholm, Sweden
| | - A J Wardlaw
- Department of Infection Immunity and Inflammation, Institute for Lung Health, University of Leicester, Leicester, UK.,Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
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Matulonga B, Rava M, Siroux V, Bernard A, Dumas O, Pin I, Zock JP, Nadif R, Leynaert B, Le Moual N. Women using bleach for home cleaning are at increased risk of non-allergic asthma. Respir Med 2016; 117:264-71. [PMID: 27492540 DOI: 10.1016/j.rmed.2016.06.019] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 06/10/2016] [Accepted: 06/24/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Bleach is widely used for household cleaning. Although it is recognized that occupational use of bleach may have adverse respiratory health effects, it is unknown whether common domestic use of bleach may be a risk factor for asthma. AIM To assess whether the domestic use of bleach for home cleaning is associated with asthma and other respiratory outcomes. METHODS Questionnaire-based information on respiratory symptoms and cleaning habits and data from skin prick-tests, bronchial responsiveness challenge and white blood cells were analyzed in 607 women participating in the follow-up of the Epidemiological Study on the Genetics and Environment of Asthma (EGEA). Bleach use was evaluated in 3 categories (<1 day/week; 1-3 days/week; 4-7 days/week "frequent"). RESULTS Overall, 37% of the women reported using bleach weekly. Women using bleach frequently (11%) were more likely to have current asthma as compared to non-users (adjusted Odds-Ratio (aOR) = 1.7; 95% Confidence Interval (95%CI) 1.0-3.0). Among women with asthma, frequent use of bleach was significantly associated with higher blood neutrophil cell counts. Bleach use was significantly associated with non-allergic asthma (aOR 3.3; 95%CI 1.5-7.1), and more particularly with non-allergic adult-onset asthma (aOR 4.9; 95%CI 2.0-11.6). Consistently, among women without allergic sensitization, significant positive associations were found between use of bleach and bronchial hyperresponsiveness, asthma like-symptoms and chronic cough. No association was observed for allergic asthma. CONCLUSIONS Frequent use of bleach for home-cleaning is associated with non-allergic adult-onset asthma, elevated neutrophil counts and lower-airway symptoms in women.
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Affiliation(s)
- Bobette Matulonga
- Inserm, UMR 1152, Pathophysiology and Epidemiology of Respiratory Diseases, Epidemiology Team, F-75890, Paris, France; Univ Paris-Saclay, Faculty of Medicine, Kremlin-Bicêtre, France
| | - Marta Rava
- Inserm, U1168, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, F-94807, Villejuif, France; Univ Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France; Genetic and Molecular Epidemiology Group, Spanish National Cancer Research Center (CNIO), Madrid, Spain
| | - Valérie Siroux
- University Grenoble Alpes, IAB, Team of Environmental Epidemiology Applied to Reproduction and Respiratory Health, F-38042, Grenoble, France; Inserm U823, IAB, Team of Environmental Epidemiology Applied to Reproduction and Respiratory Health, F-38042, Grenoble, France
| | - Alfred Bernard
- Louvain Center for Toxicology and Applied Pharmacology (LTAP), Catholic University of Louvain, 1200, Brussels, Belgium
| | - Orianne Dumas
- Inserm, U1168, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, F-94807, Villejuif, France; Univ Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
| | - Isabelle Pin
- University Grenoble Alpes, IAB, Team of Environmental Epidemiology Applied to Reproduction and Respiratory Health, F-38042, Grenoble, France; Inserm U823, IAB, Team of Environmental Epidemiology Applied to Reproduction and Respiratory Health, F-38042, Grenoble, France; CHU de Grenoble, La Tronche, F-38043, Grenoble, France
| | - Jan-Paul Zock
- Center for Research in Environmental Epidemiology (CREAL), Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Rachel Nadif
- Inserm, U1168, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, F-94807, Villejuif, France; Univ Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
| | - Bénédicte Leynaert
- Inserm, UMR 1152, Pathophysiology and Epidemiology of Respiratory Diseases, Epidemiology Team, F-75890, Paris, France; University Paris Diderot Paris 7, UMR 1152, F-75890, Paris, France.
| | - Nicole Le Moual
- Inserm, U1168, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, F-94807, Villejuif, France; Univ Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
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Anderson SE, Shane H, Long C, Lukomska E, Meade BJ, Marshall NB. Evaluation of the irritancy and hypersensitivity potential following topical application of didecyldimethylammonium chloride. J Immunotoxicol 2016; 13:557-66. [PMID: 27216637 DOI: 10.3109/1547691x.2016.1140854] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Didecyldimethylammonium chloride (DDAC) is a dialkyl-quaternary ammonium compound that is used in numerous products for its bactericidal, virucidal and fungicidal properties. There have been clinical reports of immediate and delayed hypersensitivity reactions in exposed individuals; however, the sensitization potential of DDAC has not been thoroughly investigated. The purpose of these studies was to evaluate the irritancy and sensitization potential of DDAC following dermal exposure in a murine model. DDAC induced significant irritancy (0.5 and 1%), evaluated by ear swelling in female Balb/c mice. Initial evaluation of the sensitization potential was conducted using the local lymph node assay (LLNA) at concentrations ranging from 0.0625-1%. A concentration-dependent increase in lymphocyte proliferation was observed with a calculated EC3 value of 0.17%. Dermal exposure to DDAC did not induce increased production of IgE as evaluated by phenotypic analysis of draining lymph node B-cells (IgE (+) B220(+)) and measurement of total serum IgE levels. Additional phenotypic analyses revealed significant and dose-responsive increases in the absolute number of B-cells, CD4 (+) T-cells, CD8 (+) T-cells and dendritic cells in the draining lymph nodes, along with significant increases in the percentage of B-cells (0.25% and 1% DDAC) at Day 10 following 4 days of dermal exposure. There was also a significant and dose-responsive increase in the number of activated CD44 (+) CD4 (+) and CD8 (+) T-cells and CD86 (+) B-cells and dendritic cells following exposure to all concentrations of DDAC. These results demonstrate the potential for development of irritation and hypersensitivity responses to DDAC following dermal exposure and raise concerns about the use of this chemical and other quaternary ammonium compounds that may elicit similar effects.
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Affiliation(s)
- Stacey E Anderson
- a Health Effects Laboratory Division , National Institute for Occupational Safety and Health , Morgantown , WV , USA
| | - Hillary Shane
- a Health Effects Laboratory Division , National Institute for Occupational Safety and Health , Morgantown , WV , USA
| | - Carrie Long
- a Health Effects Laboratory Division , National Institute for Occupational Safety and Health , Morgantown , WV , USA
| | - Ewa Lukomska
- a Health Effects Laboratory Division , National Institute for Occupational Safety and Health , Morgantown , WV , USA
| | - B Jean Meade
- a Health Effects Laboratory Division , National Institute for Occupational Safety and Health , Morgantown , WV , USA
| | - Nikki B Marshall
- a Health Effects Laboratory Division , National Institute for Occupational Safety and Health , Morgantown , WV , USA
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81
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Weber DJ, Consoli SA, Rutala WA. Occupational health risks associated with the use of germicides in health care. Am J Infect Control 2016; 44:e85-9. [PMID: 27131141 DOI: 10.1016/j.ajic.2015.11.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 11/20/2015] [Indexed: 11/16/2022]
Abstract
Environmental surfaces have been clearly linked to transmission of key pathogens in health care facilities, including methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, Clostridium difficile, norovirus, and multidrug-resistant gram-negative bacilli. For this reason, routine disinfection of environmental surfaces in patient rooms is recommended. In addition, decontamination of shared medical devices between use by different patients is also recommended. Environmental surfaces and noncritical shared medical devices are decontaminated by low-level disinfectants, most commonly phenolics, quaternary ammonium compounds, improved hydrogen peroxides, and hypochlorites. Concern has been raised that the use of germicides by health care personnel may increase the risk of these persons for developing respiratory illnesses (principally asthma) and contact dermatitis. Our data demonstrate that dermatitis and respiratory symptoms (eg, asthma) as a result of chemical exposures, including low-level disinfectants, are exceedingly rare. Unprotected exposures to high-level disinfectants may cause dermatitis and respiratory symptoms. Engineering controls (eg, closed containers, adequate ventilation) and the use of personal protective equipment (eg, gloves) should be used to minimize exposure to high-level disinfectants. The scientific evidence does not support that the use of low-level disinfectants by health care personnel is an important risk for the development of asthma or contact dermatitis.
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Affiliation(s)
- David J Weber
- Department of Hospital Epidemiology, University of North Carolina Health Care, Chapel Hill, NC; Department of Occupational Health, University of North Carolina Health Care, Chapel Hill, NC; Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, NC.
| | - Stephanie A Consoli
- Department of Occupational Health, University of North Carolina Health Care, Chapel Hill, NC
| | - William A Rutala
- Department of Hospital Epidemiology, University of North Carolina Health Care, Chapel Hill, NC; Department of Occupational Health, University of North Carolina Health Care, Chapel Hill, NC; Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, NC
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82
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El-Helaly M, Balkhy HH, Waseem K, Khawaja S. Respiratory symptoms and ventilatory function among health-care workers exposed to cleaning and disinfectant chemicals, a 2-year follow-up study. Toxicol Ind Health 2015; 32:2002-2008. [PMID: 26525910 DOI: 10.1177/0748233715610043] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Previous cross-sectional studies have shown that exposure to cleaning chemicals among health-care workers (HCWs) is associated with respiratory disorders and ventilatory function changes. This study aimed to further explore this association using a longitudinal approach. A prospective 2-year follow-up study was carried out at a tertiary care hospital in Saudi Arabia from June 2012 to June 2014 among 56 nurses who were responsible for disinfection and sterilization of medical instruments and equipment. The workplaces of the participants were assessed for engineering, environmental, and safety control measures. Self-administered questionnaires were distributed to all participants to assess their exposure to cleaning chemicals and their medical history. Spirometric parameters were measured for all nurses in 2012 (baseline) and again in 2014 (follow-up). The prevalence of work-related respiratory symptoms did not increase significantly over this time. Among all the spirometric parameters, only forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio decreased significantly, and only 10.7% of participants who were exposed to cleaning chemicals for more than 10 years had FEV1 and FVC less than their longitudinal normal limits at the end of the study. Smoking and gender were associated with statistically significant decreases in some of the spirometric parameters. Our 2-year follow-up study did not demonstrate significant association between exposure to cleaning chemicals among HCWs and changes in the prevalence of work-related respiratory symptoms, but indicated early effects on ventilatory function among them. The study highlights the importance of periodic spirometry, proper work practices, and effective control measures to protect HCWs against potentially harmful workplace chemicals for disinfection and sterilization.
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Affiliation(s)
- Mohamed El-Helaly
- Department of Infection Prevention and Control, King Abdulaziz Medical City, Riyadh, Saudi Arabia .,Department of Community Medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Hanan H Balkhy
- Department of Infection Prevention and Control, King Abdulaziz Medical City, Riyadh, Saudi Arabia.,King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,King Abdulla International Medical Research Center, King Saud University for Health Sciences, Riyadh, Saudi Arabia
| | - Khan Waseem
- Department of Infection Prevention and Control, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Sahdia Khawaja
- Department of Infection Prevention and Control, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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83
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Importance of specific inhalation challenge in the diagnosis of occupational asthma induced by quaternary ammonium compounds. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:819-20. [PMID: 26164808 DOI: 10.1016/j.jaip.2015.05.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 04/14/2015] [Accepted: 05/13/2015] [Indexed: 11/22/2022]
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84
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Dumas O, Varraso R, Zock JP, Henneberger PK, Speizer FE, Wiley AS, Le Moual N, Camargo CA. Asthma history, job type and job changes among US nurses. Occup Environ Med 2015; 72:482-8. [PMID: 25713153 DOI: 10.1136/oemed-2014-102547] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 02/03/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Nurses are at increased risk of occupational asthma, an observation that may be related to disinfectants exposure. Whether asthma history influences job type or job changes among nurses is unknown. We investigated this issue in a large cohort of nurses. METHODS The Nurses' Health Study II is a prospective study of US female nurses enrolled in 1989 (ages 24-44 years). Job status and asthma were assessed in biennial (1989-2011) and asthma-specific questionnaires (1998, 2003). Associations between asthma history at baseline (diagnosis before 1989, n=5311) and job type at baseline were evaluated by multinomial logistic regression. The relations of asthma history and severity during follow-up to subsequent job changes were evaluated by Cox models. RESULTS The analytic cohort included 98 048 nurses. Compared with nurses in education/administration (likely low disinfectant exposure jobs), women with asthma history at baseline were less often employed in jobs with likely high disinfectant exposure, such as operating rooms (odds ratio 0.73 (95% CI 0.63 to 0.86)) and emergency room/inpatient units (0.89 (0.82 to 0.97)). During a 22-year follow-up, nurses with a baseline history of asthma were more likely to move to jobs with lower exposure to disinfectants (HR 1.13 (1.07 to 1.18)), especially among those with more severe asthma (HR for mild persistent: 1.13; moderate persistent 1.26; severe persistent: 1.50, compared with intermittent asthma, p trend: 0.004). CONCLUSIONS Asthma history was associated with baseline job type and subsequent job changes among nurses. This may partly reflect avoidance of tasks involving disinfectant use, and may introduce bias in cross-sectional studies on disinfectant exposure and asthma in nurses.
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Affiliation(s)
- Orianne Dumas
- Channing Division of Network Medicine, Department of Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Raphaëlle Varraso
- INSERM, VIMA: Aging and chronic diseases. Epidemiological and public health approaches, U1168, F-94807, Villejuif, France UVSQ, UMR-S 1168, Université Versailles St-Quentin-en-Yvelines, Saint-Quentin-en-Yvelines, France
| | - Jan Paul Zock
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Paul K Henneberger
- Division of Respiratory Disease Studies, National Institute for Occupational Safety and Health, Morgantown, USA
| | - Frank E Speizer
- Channing Division of Network Medicine, Department of Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Aleta S Wiley
- Channing Division of Network Medicine, Department of Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Nicole Le Moual
- INSERM, VIMA: Aging and chronic diseases. Epidemiological and public health approaches, U1168, F-94807, Villejuif, France UVSQ, UMR-S 1168, Université Versailles St-Quentin-en-Yvelines, Saint-Quentin-en-Yvelines, France
| | - Carlos A Camargo
- Channing Division of Network Medicine, Department of Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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85
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Saito R, Virji MA, Henneberger PK, Humann MJ, LeBouf RF, Stanton ML, Liang X, Stefaniak AB. Characterization of cleaning and disinfecting tasks and product use among hospital occupations. Am J Ind Med 2015; 58:101-11. [PMID: 25351791 DOI: 10.1002/ajim.22393] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND Healthcare workers have an elevated prevalence of asthma and related symptoms associated with the use of cleaning/disinfecting products. The objective of this study was to identify and characterize cleaning/disinfecting tasks and products used among hospital occupations. METHODS Workers from 14 occupations at five hospitals were monitored for 216 shifts, and work tasks and products used were recorded at five-minute intervals. The major chemical constituents of each product were identified from safety data sheets. RESULTS Cleaning and disinfecting tasks were performed with a high frequency at least once per shift in many occupations. Medical equipment preparers, housekeepers, floor strippers/waxers, and endoscopy technicians spent on average 108-177 min/shift performing cleaning/disinfecting tasks. Many occupations used products containing amines and quaternary ammonium compounds for >100 min/shift. CONCLUSIONS This analysis demonstrates that many occupations besides housekeeping incur exposures to cleaning/disinfecting products, albeit for different durations and using products containing different chemicals.
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Affiliation(s)
- Rena Saito
- Division of Respiratory Disease Studies; National Institute for Occupational Safety and Health; Morgantown West Virginia
| | - M. Abbas Virji
- Division of Respiratory Disease Studies; National Institute for Occupational Safety and Health; Morgantown West Virginia
| | - Paul K. Henneberger
- Division of Respiratory Disease Studies; National Institute for Occupational Safety and Health; Morgantown West Virginia
| | - Michael J. Humann
- Division of Respiratory Disease Studies; National Institute for Occupational Safety and Health; Morgantown West Virginia
| | - Ryan F. LeBouf
- Division of Respiratory Disease Studies; National Institute for Occupational Safety and Health; Morgantown West Virginia
| | - Marcia L. Stanton
- Division of Respiratory Disease Studies; National Institute for Occupational Safety and Health; Morgantown West Virginia
| | - Xiaoming Liang
- Division of Respiratory Disease Studies; National Institute for Occupational Safety and Health; Morgantown West Virginia
| | - Aleksandr B. Stefaniak
- Division of Respiratory Disease Studies; National Institute for Occupational Safety and Health; Morgantown West Virginia
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86
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Heederik D. Cleaning agents and disinfectants: moving from recognition to action and prevention. Clin Exp Allergy 2014; 44:472-4. [PMID: 24666520 DOI: 10.1111/cea.12286] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- D Heederik
- Division of Environmental Epidemiology, Institute for Risk Assesment Sciences, Utrecht University, Utrecht, The Netherlands
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