Cleaning agent usage in healthcare professionals and relationship to lung and skin symptoms

Cleaning products: Their chemistry, effects on indoor air quality, and implications for human health

The use of cleaning and disinfecting products both at work and at home increased during the COVID-19 pandemic. Those products often include surfactants, acids/bases, carcinogens such as chloroform, and endocrine-disrupting chemicals, such as cyclosiloxanes, phthalates, and synthetic fragrances, which may cause harmful health effects among professional cleaners as well as among people exposed at home or in their workplaces. The aim of this study was to synthesize the effects of the commonly used chemical, surface cleaning and disinfecting products on indoor air quality, focusing on chemical and particulate matter pollutants, exposure, and human health in residential and public buildings. We also provide a summary of recommendations to avoid harmful exposure and suggest future research directions. PubMed, Google Scholar, Scopus, and Web of Science (WoS) were used to search the literature. Analysis of the literature revealed that the use of cleaning products and disinfectants increase occupants' exposure to a variety of harmful chemical air contaminants and to particulate matter. Occupational exposure to cleaning and disinfectant products has been linked to an increased risk of asthma and rhinitis. Residential exposure to cleaning products has been shown to have an adverse effect on respiratory health, particularly on asthma onset, and on the occurrence of asthma(-like) symptoms among children and adults. Efforts to reduce occupants' exposure to cleaning chemicals will require lowering the content of hazardous substances in cleaning products and improving ventilation during and after cleaning. Experimentally examined, best cleaning practices as well as careful selection of cleaning products can minimize the burden of harmful air pollutant exposure indoors. In addition, indirect ways to reduce exposure include increasing people's awareness of the harmfulness of cleaning chemicals and of safe cleaning practices, as well as clear labelling of cleaning and disinfecting products.

Prevalence of work-related skin symptoms and associated factors among tertiary hospital workers exposed to cleaning agents in Southern Africa

INTRODUCTION

Working with cleaning products is associated with occupational contact dermatitis in health workers (HWs), but information on predictors for these outcomes is limited.

OBJECTIVES

This study investigated the prevalence of work-related skin symptoms (WRSS) and associated factors in HWs exposed to cleaning agents in two Southern African tertiary hospitals.

METHODS

A cross-sectional study of 697 HWs used an interviewer-administered questionnaire and assessed for atopy using Phadiatop.

RESULTS

HWs' median age was 42 years, 77.0% were female and 42.5% were atopic. The prevalence of WRSS in the last 12 months was 14.8%, 12.3% had probable contact dermatitis (PCD) and 3.2% had probable contact urticaria (PCU). Technicians (ORadj 3.91) and tasks involving cleaning and disinfection of skin wounds (ORadj 1.98) were associated with WRSS in the past year. Factors associated with PCD included sterilizing instruments, disinfecting skin before procedures and use of wound adhesives. Factors associated with PCU included specimen preparation using formalin, medical instrument sterilization tasks, and skin/wound cleaning and disinfection. Appropriate glove use when performing patients' skin/wound care was protective against WRSS.

CONCLUSIONS

Tasks involving cleaning and disinfecting patients' skin and wounds were associated with WRSS in HWs, especially when performed without gloves.

Occupational risk factors and exposure-response relationships for airway disease among health workers exposed to cleaning agents in tertiary hospitals

OBJECTIVES

This study investigated occupational risk factors and exposure-response relationships for airway disease among health workers (HWs) exposed to cleaning agents in two tertiary hospitals in South Africa and Tanzania.

METHODS

In this cross-sectional study, 697 participants completed questionnaire interviews while 654 underwent fractional exhaled nitric oxide (FeNO) testing. Asthma Symptom Score (ASS) was computed based on the sum of answers to five questions on asthma-related symptoms in the past 12 months. For exposure-response analyses, cleaning agent-related self-reported exposure variables were categorised into three levels (cleaning product not used; use of a cleaning product for up to 99 min per week and use of a cleaning product for ≥100 min per week).

RESULTS

Asthma-related outcomes (ASS and FeNO) demonstrated positive associations with medical instrument cleaning agents (orthophthalaldehyde and enzymatic cleaners) and tasks (instruments precleaning and changing sterilisation solutions) as well as patient care activities (disinfection prior to procedures and disinfecting wounds). A particularly pronounced dose-response relationship was observed between work-related ocular-nasal symptoms and medical instrument cleaning agents (orthophthalaldehyde, glutaraldehyde, enzymatic cleaners, alcohols and bleach) (OR range: 2.37-4.56) and tasks (OR range: 2.92-4.44). A strong association was also observed between ASS and use of sprays for fixed surface cleaning (mean ratio 2.81; 95% CI 1.41 to 5.59).

CONCLUSIONS

Specific agents for medical instrument disinfection for example, orthophthalaldehyde and enzymatic cleaners, patient care activities and use of sprays are important occupational risk factors for airway disease among HWs.

Job and exposure intensity among hospital cleaning staff adversely affects respiratory health

BACKGROUND

Occupational exposure to various types of cleaning agents may increase the risk of adverse respiratory health among cleaners. This study investigated the relationship between exposure to cleaning and disinfecting agents, using a job-task and exposure intensity metric, and respiratory outcomes among cleaners.

METHODS

A sample of 174 cleaners was selected from three public hospitals in Durban. A questionnaire was used to collect demographic and occupational information, and spirometry, including post-bronchodilator measures, was conducted according to the American Thoracic Society guidelines and skin prick testing were performed. Exposure metrics for job tasks and chemical exposures were created using frequency and employment-lifetime duration of exposure. Multivariate analysis regression models used job task and exposure intensity metrics.

RESULTS

Doctor-diagnosed asthma prevalence was 9.8%. Breathlessness with wheeze (22.4%) was the prevalent respiratory symptom. Positive responses to skin prick testing were seen in 74 (43.2%). There was a statistically significant increased risk for shortness of breath with exposure to quaternary ammonium compounds (odds ratio [OR]: 3.44; 95% confidence interval [CI]: 1.13-10.5) and breathlessness with exposure to multipurpose cleaner (OR: 0.34; CI: 0.12-0.92). The losses in percent-predicted forced expiratory volume in 1 s (FEV1) ranged from 0.3%-6.7%. Results among the bronchodilator-positive (8.6%) showed lung function losses twofold greater when compared to the total study population with percentage predicted FEV1 (-22.6 %; p < 0.000).

CONCLUSION

Exposure to certain cleaning and disinfectant agents adversely affects respiratory health, particularly lung function. This effect, while seen generally among cleaning workers, is more pronounced among those with pre-existing reversible obstructive lung disease.

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.

Characterization of Cleaning and Disinfection Product Use, Glove Use, and Skin Disorders by Healthcare Occupations in a Midwestern Healthcare Facility

Healthcare facility staff use a wide variety of cleaning and disinfecting products during their daily operations, many of which are associated with respiratory or skin irritation or sensitization with repeated exposure. The objective of this study was to characterize the prevalence of cleaning and disinfection product use, glove use during cleaning and disinfection, and skin/allergy symptoms by occupation and identify the factors influencing glove use among the healthcare facility staff. A questionnaire was administered to the current employees at a midwestern Veterans Affairs healthcare facility that elicited information on cleaning and disinfection product use, glove use during cleaning and disinfection, skin/allergy symptoms, and other demographic characteristics, which were summarized by occupation. The central supply/environmental service workers (2% of the total survey population), nurses (26%,), nurse assistants (3%), and laboratory technicians (5%) had the highest prevalence of using cleaning or disinfecting products, specifically quaternary ammonium compounds, bleach, and alcohol. Glove use while using products was common in both patient care and non-patient care occupations. The factors associated with glove use included using bleach or quaternary ammonium compounds and using cleaning products 2-3 or 4-5 days per week. A high frequency of glove use (≥75%) was reported by workers in most occupations when using quaternary ammonium compounds or bleach. The use of alcohol, bleach, and quaternary ammonium compounds was associated with skin disorders (p < 0.05). These research findings indicate that although the workers from most occupations report a high frequency of glove use when using cleaning and disinfection products, there is room for improvement, especially among administrative, maintenance, and nursing workers. These groups may represent populations which could benefit from the implementation of workplace interventions and further training regarding the use of personal protective equipment and the potential health hazards of exposure to cleaning and disinfecting chemicals.

Characterization of Exposure to Cleaning Agents Among Health Workers in Two Southern African Tertiary Hospitals

BACKGROUND

Whilst cleaning agents are commonly used in workplaces and homes, health workers (HWs) are at increased risk of exposure to significantly higher concentrations used to prevent healthcare-associated infections. Exposure assessment has been challenging partly because many are used simultaneously resulting in complex airborne exposures with various chemicals requiring different sampling techniques. The main objective of this study was to characterize exposures of HWs to various cleaning agents in two tertiary academic hospitals in Southern Africa.

METHODS

A cross-sectional study of HWs was conducted in two tertiary hospitals in South Africa (SAH) and Tanzania (TAH). Exposure assessment involved systematic workplace observations, interviews with key personnel, passive personal environmental sampling for aldehydes (ortho-phthalaldehyde-OPA, glutaraldehyde and formaldehyde), and biomonitoring for chlorhexidine.

RESULTS

Overall, 269 samples were collected from SAH, with 62 (23%) collected from HWs that used OPA on the day of monitoring. OPA was detectable in 6 (2%) of all samples analysed, all of which were collected in the gastrointestinal unit of the SAH. Overall, department, job title, individual HW use of OPA and duration of OPA use were the important predictors of OPA exposure. Formaldehyde was detectable in 103 (38%) samples (GM = 0.0025 ppm; range: <0.0030 to 0.0270). Formaldehyde levels were below the ACGIH TLV-TWA (0.1 ppm). While individual HW use and duration of formaldehyde use were not associated with formaldehyde exposure, working in an ear, nose, and throat ward was positively associated with detectable exposures (P-value = 0.002). Glutaraldehyde was not detected in samples from the SAH. In the preliminary sampling conducted in the TAH, glutaraldehyde was detectable in 8 (73%) of the 11 samples collected (GM = 0.003 ppm; range: <0.002 to 0.028). Glutaraldehyde levels were lower than the ACGIH's TLV-Ceiling Limit of 0.05 ppm. p-chloroaniline was detectable in 13 (4%) of the 336 urine samples (GM = 0.02 ng/ml range: <1.00 to 25.80).

CONCLUSION

The study concluded that detectable exposures to OPA were isolated to certain departments and were dependent on the dedicated use of OPA by the HW being monitored. In contrast, low-level formaldehyde exposures were present throughout the hospital. There is a need for more sensitive exposure assessment techniques for chlorhexidine given its widespread use in the health sector.

Do hospital workers experience a higher risk of respiratory symptoms and loss of lung function?

Background

Hospital work environment contains various biological and chemical exposures that can affect indoor air quality and have impact on respiratory health of the staff. The objective of this study was to investigate potential effects of occupational exposures on the risk of respiratory symptoms and lung function in hospital work, and to evaluate potential interaction between smoking and occupational exposures.

Methods

We conducted a cross-sectional study of 228 staff members in a hospital and 228 employees of an office building as the reference group in Shiraz, Iran. All subjects completed a standardized ATS respiratory questionnaire and performed a spirometry test.

Results

In Poisson regression, the adjusted prevalence ratios (aPR) among the hospital staff were elevated for cough (aPR 1.90, 95% CI 1.15, 3.16), phlegm production (aPR 3.21, 95% CI 1.63, 6.32), productive cough (aPR 2.83, 95% CI 1.48, 5.43), wheezing (aPR 3.18, 95% CI 1.04, 9.66), shortness of breath (aPR 1.40, 95% CI 0.93, 2.12), and chest tightness (aPR 1.73, 95% CI 0.73, 4.12). Particularly laboratory personnel experienced increased risks of most symptoms. In linear regression adjusting for confounding, there were no significant differences in lung function between the hospital and office workers. There was an indication of synergism between hospital exposures and current smoking on FEV1/FVC% (interaction term β = − 5.37, 95% CI − 10.27, − 0.47).

Conclusions

We present significant relations between hospital work, especially in laboratories, and increased risks of respiratory symptoms. Smoking appears to enhance these effects considerably. Our findings suggest that policymakers should implement evidence-based measures to prevent these occupational exposures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-02098-5.