Household bleaches based on sodium hypochlorite: review of acute toxicology and poison control center experience

Chlorine-Induced Toxicity on Murine Cornea: Exploring the Potential Therapeutic Role of Antioxidants

Chlorine (Cl2) exposure poses a significant risk to ocular health, with the cornea being particularly susceptible to its corrosive effects. Antioxidants, known for their ability to neutralize reactive oxygen species (ROS) and alleviate oxidative stress, were explored as potential therapeutic agents to counteract chlorine-induced damage. In vitro experiments using human corneal epithelial cells showed decreased cell viability by chlorine-induced ROS production, which was reversed by antioxidant incubation. The mitochondrial membrane potential decreased due to both low and high doses of Cl2 exposure; however, it was recovered through antioxidants. The wound scratch assay showed that antioxidants mitigated impaired wound healing after Cl2 exposure. In vivo and ex vivo, after Cl2 exposure, increased corneal fluorescein staining indicates damaged corneal epithelial and stromal layers of mice cornea. Likewise, Cl2 exposure in human ex vivo corneas led to corneal injury characterized by epithelial fluorescein staining and epithelial erosion. However, antioxidants protected Cl2-induced damage. These results highlight the effects of Cl2 on corneal cells using in vitro, ex vivo, and in vivo models while also underscoring the potential of antioxidants, such as vitamin A, vitamin C, resveratrol, and melatonin, as protective agents against acute chlorine toxicity-induced corneal injury. Further investigation is needed to confirm the antioxidants' capacity to alleviate oxidative stress and enhance the corneal healing process.

A comprehensive health effects assessment of the use of sanitizers and disinfectants during COVID-19 pandemic: a global survey

COVID-19 has affected all aspects of human life so far. From the outset of the pandemic, preventing the spread of COVID-19 through the observance of health protocols, especially the use of sanitizers and disinfectants was given more attention. Despite the effectiveness of disinfection chemicals in controlling and preventing COVID-19, there are critical concerns about their adverse effects on human health. This study aims to assess the health effects of sanitizers and disinfectants on a global scale. A total of 91,056 participants from 154 countries participated in this cross-sectional study. Information on the use of sanitizers and disinfectants and health was collected using an electronic questionnaire, which was translated into 26 languages via web-based platforms. The findings of this study suggest that detergents, alcohol-based substances, and chlorinated compounds emerged as the most prevalent chemical agents compared to other sanitizers and disinfectants examined. Most frequently reported health issues include skin effects and respiratory effects. The Chi-square test showed a significant association between chlorinated compounds (sodium hypochlorite and per-chlorine) with all possible health effects under investigation (p-value <0.001). Examination of risk factors based on multivariate logistic regression analysis showed that alcohols and alcohols-based materials were associated with skin effects (OR, 1.98; 95%CI, 1.87-2.09), per-chlorine was associated with eye effects (OR, 1.83; 95%CI, 1.74-1.93), and highly likely with itching and throat irritation (OR, 2.00; 95%CI, 1.90-2.11). Furthermore, formaldehyde was associated with a higher prevalence of neurological effects (OR, 2.17; 95%CI, 1.92-2.44). Furthermore, formaldehyde was associated with a higher prevalence of neurological effects (OR, 2.17; 95%CI, 1.92-2.44). The use of sodium hypochlorite and per-chlorine also had a high chance of having respiratory effects. The findings of the current study suggest that health authorities need to implement more awareness programs about the side effects of using sanitizers and disinfectants during viral epidemics especially when they are used or overused.

Multiorgan failure and death from a mixed Dettol and Clorox poisoning: a case report

BACKGROUND

Dettol and sodium hypochlorite have wide use as household disinfectants and cleaners. Intentional and nonintentional ingestion are widespread, mainly causing mild symptoms that require no specific treatment. However, severe complications can occur when large volumes are ingested. Both products affect the same organ systems in the body, which can result in fatalities when ingested together.

CASE PRESENTATION

We present the case of a 26-year-old Asian man who died from multiorgan failure after deliberately ingesting a presumed large volume of Dettol and sodium hypochlorite. The case illustrates the severe complications that can occur with mixed ingestion of these commonly used household products.

CONCLUSION

Clinicians must be aware of the increased risk of death caused by the combined ingestion of chloroxylenol and sodium hypochlorite.

Ophthalmic Manifestations of Chlorine Gas Exposure: What Do We Know So Far?

Chlorine gas is a hazardous substance that can cause severe health effects when inhaled or exposed to the skin. It is an odorless, colorless gas in many industrial and manufacturing settings and conflict areas. While exposure to chlorine gas is generally limited to the workplace and public areas, there are instances in which people may be exposed to high levels of chlorine gas for a short period of time due to spills, mishaps on the road or railroads, or other tragedies. In addition to the general health effects of chlorine gas, this essay will focus on the effects of chlorine gas on the eyes. The eyes are particularly sensitive to chlorine gas, and exposure can cause various symptoms, ranging from mild irritation to severe damage. Symptoms of chlorine gas exposure to the eyes include redness, burning, tearing, and blurred vision. In more serious cases, exposure to chlorine gas can cause permanent damage to the eyes, including corneal ulcers, scarring, and blindness. It is important to be aware of the signs and symptoms of chlorine gas exposure and the potential long-term effects to take the necessary steps to protect oneself. In addition to the potential health effects, it is important to understand the properties of chlorine gas. Chlorine gas is heavier than air and tends to settle in low-lying areas. It is highly reactive and can react with other substances to form hazardous compounds. As such, it is important to be aware of the potential for chlorine gas to react with other environmental substances and accumulate in certain areas. Finally, it is important to understand the background of chlorine gas use in various conflict areas. Chlorine gas has been used as a chemical weapon for centuries, and its use in modern warfare has been documented in various conflicts. As such, it is important to be aware of the potential for chlorine gas to be used in war zones and to take the necessary precautions to protect oneself. In conclusion, chlorine gas is a hazardous substance that can cause severe health effects when inhaled or exposed to the skin. The eyes are particularly sensitive to chlorine gas, and exposure can cause various symptoms, ranging from mild irritation to severe damage. It is important to be aware of the signs and symptoms of chlorine gas exposure and the potential long-term effects to take the necessary steps to protect oneself. Additionally, it is important to understand chlorine gas's properties and its background use in various conflict areas.

Effects of Thymus vulgaris Oil on Sodium Hypochlorite-Induced Damage in Rats

We aimed to determine the potential damage mechanisms of exposure to widely used sodium hypochlorite (NaOCl) and the effects of Thymus vulgaris on this exposure. Rats were divided into six groups: control, T. vulgaris, 4% NaOCl, 4% NaOCl + T. vulgaris, 15% NaOCl, and 15% NaOCl + T. vulgaris. Serum and lung tissue samples were taken after applying NaOCl and T. vulgaris by inhalation twice a day for 30 min for four weeks. The samples were examined biochemically (TAS/TOS), histopathologically, and immunohistochemically (TNF-α). In serum TOS values, the mean of 15% NaOCl was significantly higher than in 15% NaOCl + T. vulgaris. This was the opposite in terms of serum TAS values. Histopathologically, there was a significant increase in lung injury in 15% NaOCl; significant improvement was observed in 15% NaOCl + T. vulgaris. Immunohistochemically, there was a significant increase in TNF-α expression in both 4% NaOCl and 15% NaOCl; significant decreases were observed in both 4% NaOCl + T. vulgaris and 15% NaOCl + T. vulgaris. The use of sodium hypochlorite, which is harmful to the lungs and is widely used in homes and industries, should be limited. In addition, using T. vulgaris essential oil by inhalation may protect against the harmful effects of sodium hypochlorite.

Near-source hypochlorous acid emissions from indoor bleach cleaning

Cleaning surfaces with sodium hypochlorite (NaOCl) bleach can lead to high levels of gaseous chlorine (Cl₂) and hypochlorous acid (HOCl); these have high oxidative capacities and are linked to respiratory issues. We developed a novel spectral analysis procedure for a cavity ring-down spectroscopy (CRDS) hydrogen peroxide (H₂O₂) analyzer to enable time-resolved (3 s) HOCl quantification. We measured HOCl levels in a residential bathroom while disinfecting a bathtub and sink, with a focus on spatial and temporal trends to improve our understanding of exposure risks during bleach use. Very high (>10 ppmv) HOCl levels were detected near the bathtub, with lower levels detected further away. Hypochlorous acid concentrations plateaued in the room at a level that depended on distance from the bathtub. This steady-state concentration was maintained until the product was removed by rinsing. Mobile experiments with the analyzer inlet secured to the researcher's face were conducted to mimic potential human exposure to bleach emissions. The findings from mobile experiments were consistent with the spatial and temporal trends observed in the experiments with fixed inlet locations. This work provides insight on effective strategies to reduce exposure risk to emissions from bleach and other cleaning products.

Recent advances in sterilization and disinfection technology: A review

Sterilization and disinfection of pollutants and microorganisms have been extensively studied in order to address the problem of environmental contamination, which is a crucial issue for public health and economics. Various form of hazardous materials/pollutants including microorganisms and harmful gases are released into the environment that enter into the human body either through inhalation, adsorption or ingestion. The human death rate rises due to various respiratory ailments, strokes, lung cancer, and heart disorders related with these pollutants. Hence, it is essential to control the environmental pollution by applying economical and effective sterilization and disinfections techniques to save life. In general, numerous forms of traditional physical and chemical sterilization and disinfection treatments, such as dry and moist heat, radiation, filtration, ethylene oxide, ozone, hydrogen peroxide, etc. are known along with advanced techniques. In this review we summarized both advanced and conventional techniques of sterilization and disinfection along with their uses and mode of action. This review gives the knowledge about the advantages, disadvantages of both the methods comparatively. Despite, the effective solution given by the advanced sterilization and disinfection technology, joint technologies of sterilization and disinfection has proven to be more effective innovation to protect the indoor and outdoor environments.

Environmental and health impacts of spraying COVID-19 disinfectants with associated challenges

Coronavirus refers to a group of widespread viruses. The name refers to the specific morphology of these viruses because their spikes look like a crown under an electron microscope. The outbreak of coronavirus disease 2019 (COVID-19) that has been reported in Wuhan, China, in December 2019, was proclaimed an international public health emergency (PHEIC) on 30 January 2020, and on 11 March 2020, it was declared as a pandemic (World Health Organization 2020). The official name of the virus was declared by the WHO as "COVID-19 virus", formerly known as "2019-nCoV", or "Wuhan Coronavirus". The International Committee on Virus Taxonomy's Coronavirus Research Group has identified that this virus is a form of coronavirus that caused a severe outbreak of acute respiratory syndrome in 2002-2003 (SARS). As a result, the latest severe acute respiratory syndrome has been classified as a corona virus 2 (SARS-CoV-2) pathogen by this committee. This disease spread quickly across the country and the world within the first 3 months of the outbreak and became a global pandemic. To stop COVID-19 from spreading, the governing agencies used various chemicals to disinfect different commercial spaces, streets and highways. However, people used it aggressively because of panic conditions, anxiety and unconsciousness, which can have a detrimental impact on human health and the environment. Our water bodies, soil and air have been polluted by disinfectants, forming secondary products that can be poisonous and mutagenic. In the prevention and spread of COVID-19, disinfection is crucial, but disinfection should be carried out with sufficient precautions to minimize exposure to harmful by-products. In addition, to prevent inhalation, adequate personal protective equipment should be worn and chemical usage, concentrations, ventilation in the room and application techniques should be carefully considered. In the USA, 60% of respondents said they cleaned or disinfected their homes more often than they had in the previous months. In addition to the robust use of disinfection approaches to combat COVID-19, we will explore safe preventative solutions here.

Mechanisms and Implications of Bacterial Invasion across the Human Skin Barrier

Atopic dermatitis (AD) is associated with a deficiency of skin lipids, increased populations of Staphylococcus aureus in the microbiome, and structural defects in the stratum corneum (SC), the outermost layer of human skin. However, the pathogenesis of AD is ambiguous, as it is unclear whether observed changes are the result of AD or contribute to the pathogenesis of the disease. Previous studies have shown that S. aureus is capable of permeating across isolated human SC tissue when lipids are depleted to levels consistent with AD conditions. In this study, we expand upon this discovery to determine the mechanisms and implications of bacterial penetration into the SC barrier. Specifically, we establish if bacteria are permeating intercellularly or employing a combination of both inter- and intracellular travel. The mechanical implications of bacterial invasion, lipid depletion, and media immersion are also evaluated using a newly developed, physiologically relevant, temperature-controlled drip chamber. Results reveal for the first time that S. aureus can be internalized by corneocytes, indicating transcellular movement through the tissue during permeation, consistent with previous theoretical models. S. aureus also degrades the mechanical integrity of human SC, particularly when the tissue is partially depleted of lipids. These observed mechanical changes are likely the cause of broken or ruptured tissue seen as exudative lesions in AD flares. This work further highlights the necessity of lipids in skin microbial barrier function.

IMPORTANCE Millions of people suffer from the chronic inflammatory skin disease atopic dermatitis (AD), whose symptoms are associated with a deficiency of skin lipids that exhibit antimicrobial functions and increased populations of the opportunistic pathogen Staphylococcus aureus. However, the pathogenesis of AD is ambiguous, and it remains unclear if these observed changes are merely the result of AD or contribute to the pathogenesis of the disease. In this article, we demonstrate the necessity of skin lipids in preventing S. aureus from penetrating the outermost barrier of human skin, thereby causing a degradation in tissue integrity. This bacterial permeation into the viable epidermis could act as an inflammatory trigger of the disease. When coupled with delipidated AD tissue conditions, bacterial permeation can also explain increased tissue fragility, potentially causing lesion formation in AD patients that results in further enhancing bacterial permeability across the stratum corneum and the development of chronic conditions.

Health effects of sodium hypochlorite: review of published case reports

Sodium hypochlorite is widely used as the main component of cleaners and has an excellent bleaching and sterilizing effect in living and medical environments. In addition to bleaching, it is used for wastewater treatment and for sterilization in food factories, and also for disinfectants during the COVID-19 pandemic. This study analyzed reports of the health effects of sodium hypochlorite and classified them by toxicity along the exposure pathway. Most case reports described the health effects of acute high-concentration exposure, with a common case being dental exposure, mainly during treatment.

Health consequences of disinfection against SARS-CoV-2: Exploring oxidative stress damage using a biomonitoring approach

Individuals who get involved in the disinfection of public settings using sodium hypochlorite might suffer adverse health effects. However, scarce information is available on the potential oxidative stress damage caused at low concentrations typically used for disinfection. We aimed to assess whether exposure to sodium hypochlorite during the COVID-19 pandemic causes oxidative stress damage in workers engaged in disinfection tasks. 75 operators engaged in the disinfection of public places were recruited as the case group, and 60 individuals who were not exposed to disinfectant were chosen as the control group. Spot urine samples were collected before (BE) and after exposure (AE) to disinfectants in the case group. Likewise, controls provided two spot urine samples in the same way as the case group. Urinary malondialdehyde (MDA) levels were quantified by forming thiobarbituric acid reactive substances in the urine. In addition, the concentration of 8-hydroxy-2'-deoxyguanosine (8-OHdG) in the urine was determined using an ELISA kit. Results showed significant differences in the urinary levels of oxidative stress markers, where median 8-OHdG (AE case: 3.84 ± 2.89 μg/g creatinine vs AE control 2.54 ± 1.21 μg/g creatinine) and MDA (AE case: 169 ± 89 μg/g creatinine vs AE control 121 ± 47 μg/g creatinine) levels in case group AE samples were 1.55 and 1.35-times higher than the control group AE samples (P < 0.05), respectively. Besides, urinary levels of oxidative stress markers in AE samples of the case group were significantly higher than in BE samples (8-OHdG BE 3.40 ± 1.95 μg/g creatinine, MDA BE 136 ± 51.3 μg/g creatinine, P < 0.05). Our results indicated that exposure to even low levels of sodium hypochlorite used in disinfection practices might cause oxidative stress related damage. With this in mind, implementing robust protective measures, such as specific respirators, is crucial to reduce the health burdens of exposure to disinfectants.

The use of different detergents in skeletal preparations

Skeletal preparation has become an integral component within the field of forensic anthropology. The aim of this study was to determine which commercial detergent was most effective and efficient for use in skeletal preparation. The hind limbs of 24 pigs (Sus scrofa) and five detergents with bleaching agents and enzymes (Surf and Ariel), only enzymes (OMO Auto and Sunlight powder) or only bleaching agents (Sunlight dishwashing liquid) were used. Specimens were skinned and immersed into a pre-heated 6 L detergent solution or tap water and macerated at either 45 °C, 50 °C, 55 °C and 60 °C. When maceration was deemed complete any remaining soft tissue was manually removed under running tap water and the remains left to dry. A scoring system was utilized to assess the effectiveness and efficiency of each detergent. OMO Auto specimens only required a single day to complete macerate regardless of the temperature and these specimens constantly scored better than the other detergents used, thus making it the most effective and efficient detergent tested.

Personal Passive Air Samplers for Chlorinated Gases Generated from the Use of Consumer Products

Various chlorine-based disinfectants are being used during the COVID-19 pandemic; however, only a few studies on exposure to harmful gases resulting from the use of these disinfectants exist. Previously, we developed a personal passive air sampler (PPAS) to estimate the exposure level to chlorine gas while using chlorinated disinfectants. Herein, we investigated the color development of the passive sampler corresponding to chlorine exposure concentration and time, which allows the general population to easily estimate their gas exposure levels. The uptake and reaction rate of PPAS are also explained, and the maximum capacity of the sampler was determined as 1.8 mol of chlorine per unit volume (m³) of the passive sampler. Additionally, the effects of disinfectant types on the gas exposure level were successfully assessed using passive samplers deployed in a closed chamber. It is noteworthy that the same level of chlorine gas is generated from liquid household bleach regardless of dilution ratios, and we confirmed that the chlorine gas can diffuse out from a gel-type disinfectant. Considering that this PPAS reflects reactive gas removal, individual working patterns, and environmental conditions, this sampler can be successfully used to estimate personal exposure levels of chlorinated gases generated from disinfectants.

Development of a personal passive air sampler for estimating exposure to effective chlorine while using chlorine-based disinfectants

With an increasing use of indoor disinfectants such as chlorine (Cl₂ ) and hypochlorous acid, a convenient sampler for estimating exposure to oxidants, such as effective chlorine, is necessary. Here, we developed a personal passive air sampler (PPAS) composed of a redox dye, o-dianisidine, in a polydimethylsiloxane (PDMS) sheet. o-Dianisidine readily reacts with gaseous oxidants generated by bleach usage, and its color changes as the reaction progresses; hence, personal exposure to effective chlorine could be easily detected by the naked eye, while cumulative exposure could be determined by measuring concentrations of o-dianisidine reacting with it. The PPAS was calibrated, and a sampling rate of 0.00253 m³ /h was obtained using a small test chamber. The PPAS was tested with the help of ten volunteers whose personal exposure to Cl₂ -equivalent gas was estimated after bathrooms were cleaned using spray and liquid-type household disinfection products, and the accumulated exposure-gas concentrations ranged from 69 to 408 ppbv and 148 to 435 ppbv, respectively. These PPAS-derived exposure concentrations were approximately two orders lower than those estimated using ConsExpo, suggesting a significant overestimation by prevailing screening models, possibly due to the ignorance of transformation reactions.

In vitro inactivation of SARS-CoV-2 by commonly used disinfection products and methods

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection is currently a global pandemic, and there are limited laboratory studies targeting pathogen resistance. This study aimed to investigate the effect of selected disinfection products and methods on the inactivation of SARS-CoV-2 in the laboratory. We used quantitative suspension testing to evaluate the effectiveness of the disinfectant/method. Available chlorine of 250 mg/L, 500 mg/L, and 1000 mg/L required 20 min, 5 min, and 0.5 min to inactivate SARS-CoV-2, respectively. A 600-fold dilution of 17% concentration of di-N-decyl dimethyl ammonium bromide (283 mg/L) and the same concentration of di-N-decyl dimethyl ammonium chloride required only 0.5 min to inactivate the virus efficiently. At 30% concentration for 1 min and 40% and above for 0.5 min, ethanol could efficiently inactivate SARS-CoV-2. Heat takes approximately 30 min at 56 °C, 10 min above 70 °C, or 5 min above 90 °C to inactivate the virus. The chlorinated disinfectants, Di-N-decyl dimethyl ammonium bromide/chloride, ethanol, and heat could effectively inactivate SARS-CoV-2 in the laboratory test. The response of SARS-CoV-2 to disinfectants is very similar to that of SARS-CoV.

Chlorine exposure during a biological decontamination study in a mock subway tunnel

The Underground Transport Restoration (UTR) Operational Technology Demonstration (OTD) was a full-scale field study focused on remediation of a subway system after contamination with a Bacillus anthracis (Ba) surrogate (Bacillus atrophaeus, subspecies globigii [Bg]). The study involved all aspects of subway system remediation following contamination with a biological surrogate, including characterization, clearance sampling, and waste management.^{[ 1 ]} Personal exposure to chlorine gas was also monitored throughout the decontamination portion of the study. Process-based personal monitoring for chlorine was conducted using portable single gas monitors with chlorine sensors during Level A entry into the biologically-contaminated area (exclusion zone) during spraying operations. Additional monitoring was conducted during the mixing of pH-adjusted bleach solutions and waste item decontamination (immersion dunking). An analysis of variance was performed to compare process-based time-averaged chlorine exposure among the similar exposure groups. Chlorine exposure was highest for the Decon Sprayers, which was expected based on their proximity to the spray streams. Peak exposure levels (5-sec readings) ranged from 11 to at least 50 parts per million (ppm). It is likely that exposure exceeded 50 ppm, but this was the upper limit of measurement. Oversight personnel were farther away from the spray operation but still had significant peak chlorine exposures of 13-26 ppm. The rail cart operators had peak exposures of 13-19 ppm. Statistically significant differences were observed between time-weighted average exposure levels of Decon Sprayers and the other workers. Spraying of pH-adjusted bleach solution on subway tunnel surfaces for biological decontamination produced up to 50 ppm chlorine vapor in the air that far exceeded the occupational exposure limits of 0.5-1 ppm for chlorine, as well as the Immediately Dangerous to Life or Health limit of 10 ppm. Health and safety plans and operational activities must provide appropriate worker protection during such events where potential for chlorine overexposure has been demonstrated.

Heterogeneous Chlorination of Squalene and Oleic Acid

Washing with chlorine bleach leads to high mixing ratios of gas-phase HOCl. Using two methods that are sensitive to surface film composition-attenuated total reflection fourier transform infrared (ATR-FTIR) spectroscopy and direct analysis in real time mass spectrometry (DART-MS)-we present the first study of the chlorination chemistry that occurs when gaseous HOCl reacts with thin films of squalene and oleic acid. At mixing ratios of 600 ppbv, HOCl forms chlorohydrins by adding across carbon-carbon double bonds without breaking the carbon backbone. The initial uptake of one HOCl molecule occurs on the time scale of a few minutes at these mixing ratios. For oleic acid, ester formation proceeds immediately thereafter, leading to dimeric and trimeric chlorinated products. For squalene, subsequent HOCl uptake occurs until all six of its carbon-carbon double bonds become chlorinated within 1-2 h. These results indicate that chlorination of skin oil, which contains substantial carbon unsaturation, is likely to occur rapidly under common cleaning conditions, potentially leading to the irritation associated with chlorinated bleach. This chemistry will likely also proceed with cooking oils, in the human respiratory system which has unsaturated surfactants as important components of lung fluid, and with organic components of the sea surface microlayer.

Low dose of chlorine exposure exacerbates nasal and pulmonary allergic inflammation in mice

Work-exacerbated asthma (WEA) is defined as preexisting asthma that worsens with exposure to irritants [e.g., chlorine (Cl₂) derivatives] in the workplace. The maximum allowable concentration in the workplace of Cl₂ exposure is 3 mg/ m³ (described in OSHA). We investigated in an experimental asthma model in mice the effects of a single exposure to a sodium hypochlorite dose with this allowed chlorine concentration and a tenfold higher dose. Acute chlorine exposure at 3.3 mg/m³ in the OVA-sensitized group increased eosinophils in the peribronquial infiltrate, cytokine production, nasal mucus production and the number of iNOS positive cells in the distal lung compared to only sensitized mice. The exposure to a higher dose of 33.3 mg/m³ in the OVA-sensitized group resulted in an increase in respiratory system elastance, in the total and differential numbers of inflammatory cells in bronchoalveolar lavage fluid, IL-4, IL-5, and IL-17 in the lungs, eosinophils in peribronquial infiltrate and mucus content in nasal compared to non-exposed and sensitized animals. In this asthma model, chorine exposures at an allowable dose, contributed to the potentiation of Th2 responses. The functional alterations were associated with increased iNOS and ROCK-2 activation in the distal lung.

Accidental Use of Sodium Hypochlorite Instead of Haemodialysis Solution: A Case Report

Haemodialysis that involves diffusion of solutes across a semi-permeable membrane allows excretion of harmful solutes and excess fluids. All dialysis machines are disinfected by chemical agents (e.g. sodium hypochlorite, formaldehyde, glutaraldehyde, peroxyacetic acid). Sodium hypochlorite (NaOCl), which is known as household bleach, is a whitening agent and used in medical treatment and disinfection of tap water. Herein, we present a 66-year-old female patient who was inadvertently connected to NaOCl solution infusion in a routine haemodialysis session. By the time the accident was noticed, approximately 200 ml of undiluted NaOCl cleaning solution (concentration 1.21-1.23 g/ml) had been added to the dialysis bath, soaking the membrane fibres. The patient was admitted to the hospital about 30 minutes after the exposure, and her Glasgow Coma Scale score was recorded as 5/15 (E1, V1, M3). In conclusion, more stringent standards should be enforced in the sterilization of haemodialysis machines and related equipments. Accidental contacts with disinfectants should be prevented in dialysis units.

Inactivation of porcine epidemic diarrhea virus using heated water

Porcine epidemic diarrhea virus (PEDV) is a very contagious swine pathogen that spreads easily via the fecal-oral route, notably from contaminated fomites. The present study investigated heated water as a method for rapid thermal inactivation of PEDV. Cell-culture adapted PEDV was treated with water at varying temperatures and viral titers were measured at multiple time points post-treatment. Viable PEDV was not recovered after a ten second or longer treatment with water heated to ≥76 °C; however, PEDV nucleic acid was detected in all samples regardless of treatment. Hot water decontamination could be considered in settings where chemical disinfection is impractical.

Self-injection of household cleaning detergents into a ventriculoperitoneal shunt reservoir during a suicide attempt: a case report and literature review

Self-injection of household cleaning detergents (more specifically, commercial toilet bowl cleaner) into the reservoir of a ventriculoperitoneal shunt (VPS) has never been reported in the neurosurgical literature. A right-handed 41-year-old female with a past medical history significant for bipolar depression (with multiple prior hospital admissions for suicide attempts) and pseudotumor cerebri (status-post VPS placement from a right frontal approach) successfully injected ∼5 ml of toilet bowl cleaner into her ventricular shunt reservoir during a suicide attempt. She was found unresponsive by a family member 48 h after this event and presented to our hospital in moribund neurological condition (bilaterally fixed and dilated pupils with decerebrate posturing). Head computed tomography (CT) demonstrated marked ventriculomegaly. She was taken emergently to the operating room for placement of a left frontal ventriculostomy. Cerebrospinal fluid (CSF) sampled intraoperatively showed numerous Gram-positive cocci (later determined to be Staphylococcus epidermidis). For this reason, her right-sided shunt system was also removed in its entirety. She was treated with broad-spectrum intravenous and intraventricular antibiotics for her bacterial ventriculitis and her CSF was aggressively drained to treat her hydrocephalus. Once her infection had resolved, the shunt was replaced (using a right parietal approach) and she went on to make an excellent neurological recovery. Here, the authors present the case of a patient who self-injected household cleaning detergents into her VPS reservoir-and, likely, the ventricular system-during a suicide attempt and subsequently developed hydrocephalus and ventriculitis. Following this infrequent clinical scenario, consideration should be given to temporary ventriculostomy placement and shunt removal. Moreover, in patients with a known history of psychiatric co-morbidities-and particularly those patients with prior suicide attempts-the neurosurgeon should give serious consideration to placing the shunt system in an anatomical region which is difficult for the patient to self-access based upon their handedness.

Women using bleach for home cleaning are at increased risk of non-allergic asthma

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.

N-acetylcysteine infusion in preventing hepatotoxicity secondary to intravenous injection of household bleach

We present a case of non-accidental injection of 40 ml of domestic bleach through a long-term central venous catheter (CVC) with subsequent AKI, and for the first time in the literature severe coagulopathy and acute liver injury. We detail the clinical course of events and our management plan which adds to the body of evidence for prognosis and treatment in these unusual cases.

Effects of disinfection on the molecular detection of porcine epidemic diarrhea virus

Routine detection of porcine epidemic diarrhea virus (PEDV) is currently limited to RT-PCR but this test cannot distinguish between viable and inactivated virus. We evaluated the capability of disinfectants to both inactivate PEDV and sufficiently damage viral RNA beyond RT-PCR detection. Five classes of disinfectants (phenol, quaternary ammonium compound, sodium hypochlorite, oxidizing agent, and quaternary ammonium/glutaraldehyde combination) were evaluated in vitro at varying concentrations, both in the presence and absence of swine feces, and at three different temperatures. No infectious PEDV was recovered after treatment with evaluated disinfectants. Additionally, all tested disinfectants except for 0.17% sodium hypochlorite dramatically reduced qRT-PCR values. However, no disinfectants eliminated RT-PCR detection of PEDV across all replicates; although, 0.52%, 1.03% and 2.06% solutions of sodium hypochlorite and 0.5% oxidizing agent did intermittently produce RT-PCR negatives. To simulate field conditions in a second aim, PEDV was applied to pitted aluminum coupons, which were then treated with either 2.06% sodium hypochlorite or 0.5% oxidizing agent. Post-treatment surface swabs of the coupons tested RT-PCR positive but were not infectious to cultured cells or naïve pigs. Ultimately, viable PEDV was not detected following application of each of the tested disinfectants, however in most cases RT-PCR detection of viral RNA remained. RT-PCR detection of PEDV is likely even after disinfection with many commercially available disinfectants.

[Caustic injury of upper gastrointestinal tract: 20 year experience at a tertiary referral center]

BACKGROUND/AIMS

Caustic ingestion can cause severe injury to upper gastrointestinal tract. There were few studies about clinical characteristics and treatments of caustic injury in Korea. We investigated the changes in clinical features of caustic injury over the past 20 years including pattern of endoscopic mucosal injury and treatment modality.

METHODS

This study was a retrospective review of medical records from patients with caustic injury from September 1993 through December 2012. Patients were classified into two groups based on the year when caustic ingestion occurred: patients who visited the hospital from 1993 to 2002 (early group) and patients who visited the hospital from 2003 to 2012 (late group).

RESULTS

A total 140 patients were included (early group [n=50] vs. late group [n=90]). Annual number of caustic ingestions did not show decreasing tendency over the past 20 years. Alkali ingestion increased (20.0% vs. 65.6%, p<0.001) and cases with more than grade 2b of esophageal mucosal injury decreased (41.3% vs. 20.7%, p=0.012) in late group. There were no differences between two groups in sex, age, proportion of accidental ingestion, and systemic/gastrointestinal complications. Use of gastric lavage (p<0.01) and broad spectrum antibiotics (p=0.03) decreased in late group. However, there was no difference in use of steroid between two groups.

CONCLUSIONS

In this study, overall caustic ingestion did not decrease and ingestion of alkali agents increased over the past 20 years. Tighter legislation on caustic agents is required and we need to be alert to the best management of caustic injury.

Asthma and exposure to cleaning products - a European Academy of Allergy and Clinical Immunology task force consensus statement

Professional and domestic cleaning is associated with work-related asthma (WRA). This position paper reviews the literature linking exposure to cleaning products and the risk of asthma and focuses on prevention. Increased risk of asthma has been shown in many epidemiological and surveillance studies, and several case reports describe the relationship between exposure to one or more cleaning agents and WRA. Cleaning sprays, bleach, ammonia, disinfectants, mixing products, and specific job tasks have been identified as specific causes and/or triggers of asthma. Because research conclusions and policy suggestions have remained unheeded by manufactures, vendors, and commercial cleaning companies, it is time for a multifaceted intervention. Possible preventive measures encompass the following: substitution of cleaning sprays, bleach, and ammonia; minimizing the use of disinfectants; avoidance of mixing products; use of respiratory protective devices; and worker education. Moreover, we suggest the education of unions, consumer, and public interest groups to encourage safer products. In addition, information activities for the general population with the purpose of improving the knowledge of professional and domestic cleaners regarding risks and available preventive measures and to promote strict collaboration between scientific communities and safety and health agencies are urgently needed.

Use of bleach baths for the treatment of infected atopic eczema

Atopic eczema is one of the most common skin disorders in young children and also affects adults. Staphylococcus aureus infection is the most frequent complication of atopic eczema and is involved in the worsening of the disease. Antibiotic therapy against S. aureus has been an important component of treatment for atopic eczema but there are concerns about antibiotic overuse and increasing bacterial resistance. This has led some clinicians to recommend the use of homemade remedies such as bleach baths as an adjunctive treatment for patients with infected atopic eczema, despite the fact that there have been few published studies in this area. Balancing safety concerns with efficacious treatment is of particular importance in the paediatric population. This review discusses the historical use of bleach in medicine as well as its recent use for atopic eczema. Further, the chemistry and safety of bleach as well as alternative therapies are examined.

Venous thrombosis following intravenous injection of household bleach

Sodium hypochlorite (NaClO) is used extensively as a disinfectant or bleaching agent. Most studies describe ingestion or inhalation route of this product with rare complication and fatalities. Despite global daily exposures, data about bleach injection is limited. Here we report intentional infusion of 20 mL, sodium hypochlorite 5% diluted in 500 mL normal saline 1.5 h prior admission. Clinical manifestation included local pain and edema. There were no laboratory abnormalities in the patient. Doppler sonography revealed thrombosis in superficial (antecubital and basilic) veins. Limb elevation, warm compress, and ibuprofen relived pain and edema after 3 days.

Effects of the disinfectant Virkon S on early life-stages of the moor frog (Rana arvalis)

Emerging diseases, such as the chytrid fungus Batrachochytrium dendrobatidis, contribute to global population declines of amphibians. Virkon S is one of the most commonly used disinfectants to reduce risk of spreading such pathogens. Virkon S is classified as harmful to aquatic organisms, but until today no negative effects on tadpoles have been reported. We studied the effects of three concentrations of Virkon S on early life-stages (embryos and hatchlings) of the moor frog Rana arvalis. Overall, Virkon S had no significant effects. However, hatching success was highest in the control treatment, suggesting that Virkon S may have weak negative effects on amphibian embryos. We suggest that further studies are needed to assess the negative effect of Virkon S on amphibians, and recommend that Virkon S is used with care and a minimized run-off into natural wetlands.

Chemical Burn Induced by Cutaneous Exposure to a Concentrated Sodium Hypochlorite and Alkyl Sulfate Solution

BACKGROUND

Acute irritant contact dermatitis induced by cutaneous exposure to chemicals is a common dermatologic problem in the workplace. In severe cases, irritant contact responses can result in a caustic burn. Chemical burn induced by concentrated sodium hypochlorite (the active ingredient in bleach) has been reported infrequently in the literature, with no previously reported cases of chemical burn due to an alkyl sulfate (a common surfactant in cleaning fluids). Here we describe a chemical burn in a 16-year-old girl resulting from exposure to a solution of concentrated sodium hypochlorite and alkyl sulfate applied as a sanitizer to the interior of roller skates worn at work.

OBSERVATIONS

The diagnosis was made on the basis of the patient's exposure history, clinical appearance, and laboratory results. On physical examination, the erythematous plaque, located at the site of chemical exposure, had intact skin lines, surrounding edema, and decreased sensitivity to touch. The peripheral white blood cell count was within normal limits and bacterial and fungal cultures from the lesion were negative.

CONCLUSIONS

The irritant effect of exposure to chemicals, including those that usually are not major irritants, and the possible additive effect of simultaneous exposure to different chemicals, should be considered in the differential diagnosis of acute dermatitis of unknown etiology. Moreover, increased reporting of cases of chemical-induced acute irritant contact dermatitis will help lead to crucial early and appropriate treatment.

Appearance of chemical burns resulting from the washing of a deceased body with bleach

The authors report on a case of postmortem washing of a body with bleach. An adult female victim was found nude in an alleyway with both hands removed in the City of Westminster, CO. Cause of death was attributed to severe blunt force trauma to the head. The victim had been dumped in the alleyway within 7 h of discovery. Evidence discovered at the crime scene and autopsy indicated that the murder and subsequent washing of the body with bleach occurred at a secondary location(s). The victim was wet to the touch, presenting a strong odor of bleach. Several "ribbon"-like burn patterns were observed on the victim's back and upper thighs. These burn marks were replicated by dowsing a deceased pig with an over-the-counter concentration of bleach.

House cleaning with chlorine bleach and the risks of allergic and respiratory diseases in children

Chlorine bleach or sodium hypochlorite can inactivate common indoor allergens. In this cross-sectional study we evaluated to what extent regular house cleaning with bleach can influence the risks of respiratory and allergic diseases in children. We studied a group of 234 schoolchildren aged 10-13 yr among whom 78 children were living in a house cleaned with bleach at least once per week. Children examination included a questionnaire, an exercise-induced bronchoconstriction test and the measurement of exhaled nitric oxide (NO) and of serum total and aeroallergen-specific immunoglobulin (Ig)E, Clara cell protein (CC16) and surfactant-associated protein D (SP-D). Children living in a house regularly cleaned with bleach were less likely to have asthma (OR, 0.10; CI, 0.02-0.51), eczema (OR, 0.22; CI, 0.06-0.79) and of being sensitized to indoor aeroallergens (OR, 0.53; CI, 0.27-1.02), especially house dust mite (OR, 0.43; CI, 0.19-0.99). These protective effects were independent of gender, ethnicity, previous respiratory infections, total serum IgE level and of family history of allergic diseases. They were however abolished by parental smoking, which also interacted with the use of bleach to increase the risk of recurrent bronchitis (OR, 2.03; CI, 1.12-3.66). House cleaning with bleach had effect neither on the sensitization to pollen allergens, nor on the levels of exhaled NO and of serum CC16 and SP-D. House cleaning with chlorine bleach appears to protect children from the risks of asthma and of sensitization to indoor allergens while increasing the risk of recurrent bronchitis through apparently an interaction with parental smoking. As chlorine bleach is one of the most effective cleaning agent to be found, these observations argue against the idea conveyed by the hygiene hypothesis that cleanliness per se increases the risk of asthma and allergy.

Field stimulation-induced tetrodotoxin-resistant vasorelaxation is mediated by sodium hypochlorite

This study was done to determine the mechanism of field stimulation-induced tetrodotoxin (TTX)- and NG- nitro-l-arginine (LNA)-resistant vasorelaxation. Field stimulation with platinum and carbon, but not with silver, electrodes (30 V, 30 HZ, 2-5 ms pulse width) as well as electrically stimulated salt (0.9% NaCl) solution (ESSS) or Krebs solution caused 100% relaxation of phenylephrine-contracted rat aortic strips, which was TTX and LNA resistant and endothelium independent. ESSS also relaxed other vascular preparations (rabbit aorta and renal artery, dog coronary artery, pig ductus arteriosus, and rat portal vein). The electric current generated hypochlorite (OCl-) and H2O2 from the salt solution; however, vasorelaxation was caused by NaOCl and not by H2O2. ESSS and NaOCl caused contraction failure of spontaneously beating right atria of rats and did not affect uterine contractions, vascular cAMP, cGMP, or the pH of the tissue bath. Field stimulation, ESSS, and NaOCl did not relax aortic preparations contracted by 32 mmol/L potassium and their vasorelaxant effects on phenylephrine-contracted rat aortic strips and rings were completely reversed by tetraethylammonium and partially by glibenclamide and iberiotoxin. We conclude that electric pulses generate the oxidant OCl- from the salt solution, which causes vasorelaxation by increasing K+ conductance.

Asthma, chronic bronchitis, and exposure to irritant agents in occupational domestic cleaning: a nested case-control study

BACKGROUND

Women employed in domestic cleaning are at increased risk for symptoms of obstructive lung disease, but the agents responsible are unknown.

AIMS

To investigate common tasks and products in occupational domestic cleaning in relation to respiratory morbidity.

METHODS

Case-control study in domestic cleaning women nested within a large population based survey of women aged 30-65 years; 160 domestic cleaning women with asthma symptoms, chronic bronchitis symptoms, or both and 386 without a history of respiratory symptoms were identified. Detailed exposures were evaluated for 40 cases who reported still having symptoms at the recruitment interview, and 155 controls who reported not having symptoms. All tasks performed and products used when cleaning houses were determined in a face-to-face interview. Lung function, methacholine challenge, and serum IgE testing were performed. Personal exposure measurements of airborne chlorine and ammonia were performed in a subsample. Associations between asthma, chronic bronchitis, and cleaning exposures were evaluated using multiple logistic regression analysis.

RESULTS

Airborne chlorine (median level 0-0.4 ppm) and ammonia (0.6-6.4 ppm) were detectable during occupational domestic cleaning activities. Cases used bleach more frequently than controls; adjusted odds ratio (OR) for intermediate exposure was 3.3 (95% CI 0.9 to 11) and for high exposure 4.9 (1.5 to 15). Other independent associations included accidental inhalation of vapours and gases from cleaning agents and washing dishes. These associations were more pronounced for cases with asthma symptoms than for those with symptoms of chronic bronchitis, but were not related to sensitisation to common allergens.

CONCLUSIONS

Asthma symptoms in domestic cleaning women are associated with exposure to bleach and possibly other irritant agents. The public health impact of the use of irritant cleaning products could be widespread since the use of these products is common both in the workplace and at home.

Ingestion of caustic substances by adults

Caustic products are responsible for the most serious cases of poisoning, which are always emergency cases. In this paper, we review demographic features and endoscopic results of the patients admitted to a university emergency department with a history of caustic substance ingestion between January 2000 and June 2003. Thirty-seven patients were included in this study. Twenty-one of the patients were female and 16 were male. The mean age of the patients was 30.9 +/- 14.7 years. The agents included sodium hypochlorite in 24 patients and hydrochloric acid in 13 patients. All the patients ingested these agents orally. The mean interval time of admission to emergency department after ingestion of caustic agent was 5.4 +/- 5.6 hours. Endoscopy was attempted in 37 patients. Endoscopic results were as follows: grade 0 in 8 (21.6%) patients, grade 1 in 17 (45.9%) patients, grade 2a in 5 (13.5%) patients, and grade 2b in 7 (18.9%) patients. We believe that early signs and symptoms after caustic substance ingestion are not consistent with the extent of damage, and endoscopy is the only reliable method to assess injury. It is important that efforts should be made to educate the public about the dangers of caustic substances so that their threat may be diminished.

Treatment of field water with sodium hypochlorite for surgical irrigation

BACKGROUND

Early irrigation and surgical debridement of high-energy wounds and open fractures effectively prevents infection. Rapid wound care has been maximized by the United States military's "forward surgical teams." However, the volume of sterile irrigant required to treat multiple patients with multiple wounds presents a significant logistical burden. Using ground-derived field water could eliminate this burden.

METHODS

We collected 100 water samples from five sources. An initial bacterial count (CFU/mL) was determined before treatment. 5% sodium hypochlorite was then added to each sample to derive a concentration of 0.025%. After treatment, a final bacterial colony count was performed.

RESULTS

We found no bacterial growth in 99/100 samples. One post-treatment sample grew a single colony of a Bacillus species not present in the pretreatment culture and was determined to be an air contaminant.

CONCLUSIONS

Our field-expedient modification of Dakin's solution could substitute for sterile irrigation fluid when it is neither available nor logistically feasible.

Tissue-dissolving capacity and antibacterial effect of buffered and unbuffered hypochlorite solutions

OBJECTIVE

The goal of this study was to compare the dissolving potential of Dakin's solution with that of equivalent buffered and unbuffered sodium hypochlorite solutions on fresh and decayed tissues. In addition, the antimicrobial effect of Dakin's solution and equivalent unbuffered hypochlorite was tested.

STUDY DESIGN

Tissue specimens were obtained from freshly dissected pig palates. Unbuffered 2.5% and 0.5% sodium hypochlorite solutions and 0.5% solutions buffered at a pH of 12 and a pH of 9 (Dakin's solution) were tested on fresh and decayed tissue. Tissue decay was assessed histologically. Antimicrobial testing was performed with Enterococcus faecalis in dentin blocks and on filter papers.

RESULTS

The 2.5% NaOCl solution was substantially more effective than the three 0.5% solutions in dissolving the test tissues. Buffering had little effect on tissue dissolution, and Dakin's solution was equally effective on decayed and fresh tissues. No differences were recorded for the antibacterial properties of Dakin's solution and an equivalent unbuffered hypochlorite solution.

CONCLUSIONS

In contrast to earlier statements, the results of this study do not demonstrate any benefit from buffering sodium hypochlorite with sodium bicarbonate according to Dakin's method. An irrigation solution with less dissolving potential may be obtained by simply diluting stock solutions of NaOCl with water.