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Mwanga HH, Dumas O, Migueres N, Le Moual N, Jeebhay MF. Airway Diseases Related to the Use of Cleaning Agents in Occupational Settings. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1974-1986. [PMID: 38432401 DOI: 10.1016/j.jaip.2024.02.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 02/13/2024] [Accepted: 02/19/2024] [Indexed: 03/05/2024]
Abstract
Exposure to disinfectants and cleaning products (DCPs) is now a well-established risk factor for work-related asthma (WRA). However, questions remain on the specific causal agents and pathophysiological mechanisms. Few studies have also reported an association between DCPs and rhinitis or chronic obstructive pulmonary disease. This review discusses the recent evidence pertaining to airway diseases attributable to occupational exposure to DCPs. In contrast to other agents, the incidence of WRA due to DCPs has increased over time. The use of DCPs in spray form has clearly been identified as an added risk factor. The mechanisms for WRA associated with DCPs remain poorly studied; however, both allergic and nonallergic responses have been described, with irritant mechanisms thought to play a major role. An early diagnostic workup based on clinical assessment accompanied by evaluation of lung function and immunological and airway inflammatory markers is important to guide optimal care and exposure avoidance to the implicated agent. Future research should focus on the effects of "green" products, pathophysiological mechanisms, and quantitative exposure assessment including the use of barcode-based methods to identify specific agents. There is an urgent need to strengthen preventive measures and interventions to reduce the burden of airway diseases associated with DCPs.
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Affiliation(s)
- Hussein H Mwanga
- Department of Environmental and Occupational Health, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Division of Occupational Medicine and Centre for Environmental & Occupational Health Research, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Orianne Dumas
- Université Paris-Saclay, UVSQ, Univ. Paris-Sud, Inserm, Équipe d'Épidémiologie Respiratoire Intégrative, CESP, Villejuif, France
| | - Nicolas Migueres
- Division of Pulmonology, Department of Chest Diseases, University Hospital of Strasbourg and Fédération de Médecine translationnelle, Strasbourg University, Strasbourg, France; UMR 7357 Laboratoire des sciences de l'ingénieur, de l'informatique et de l'imagerie ICUBE, Strasbourg, France
| | - Nicole Le Moual
- Université Paris-Saclay, UVSQ, Univ. Paris-Sud, Inserm, Équipe d'Épidémiologie Respiratoire Intégrative, CESP, Villejuif, France.
| | - Mohamed F Jeebhay
- Division of Occupational Medicine and Centre for Environmental & Occupational Health Research, School of Public Health, University of Cape Town, Cape Town, South Africa.
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Agache I, Canelo-Aybar C, Annesi-Maesano I, Cecchi L, Biagioni B, Chung F, D'Amato G, Damialis A, Del Giacco S, De Las Vecillas L, Dominguez-Ortega J, Galàn C, Gilles S, Giovannini M, Holgate S, Jeebhay M, Nadeau K, Papadopoulos N, Quirce S, Sastre J, Traidl-Hoffmann C, Walusiak-Skorupa J, Sousa-Pinto B, Salazar J, Rodríguez-Tanta LY, Cantero Y, Montesinos-Guevara C, Song Y, Alvarado-Gamarra G, Sola I, Alonso-Coello P, Nieto-Gutierrez W, Jutel M, Akdis CA. The impact of indoor pollution on asthma-related outcomes: A systematic review for the EAACI guidelines on environmental science for allergic diseases and asthma. Allergy 2024; 79:1761-1788. [PMID: 38366695 DOI: 10.1111/all.16051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/29/2024] [Accepted: 02/01/2024] [Indexed: 02/18/2024]
Abstract
Systematic review using GRADE of the impact of exposure to volatile organic compounds (VOCs), cleaning agents, mould/damp, pesticides on the risk of (i) new-onset asthma (incidence) and (ii) adverse asthma-related outcomes (impact). MEDLINE, EMBASE and Web of Science were searched for indoor pollutant exposure studies reporting on new-onset asthma and critical and important asthma-related outcomes. Ninety four studies were included: 11 for VOCs (7 for incidenceand 4 for impact), 25 for cleaning agents (7 for incidenceand 8 for impact), 48 for damp/mould (26 for incidence and 22 for impact) and 10 for pesticides (8 for incidence and 2 for impact). Exposure to damp/mould increases the risk of new-onset wheeze (moderate certainty evidence). Exposure to cleaning agents may be associated with a higher risk of new-onset asthma and with asthma severity (low level of certainty). Exposure to pesticides and VOCs may increase the risk of new-onset asthma (very low certainty evidence). The impact on asthma-related outcomes of all major indoor pollutants is uncertain. As the level of certainty is low or very low for most of the available evidence on the impact of indoor pollutants on asthma-related outcomes more rigorous research in the field is warranted.
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Affiliation(s)
- Ioana Agache
- Faculty of Medicine, Transylvania University, Brasov, Romania
| | - Carlos Canelo-Aybar
- Institut de Recerca Sant Pau (IR SANT PAU), Barcelona, Spain
- Centro Cochrane Iberoamericano, Sant Antoni Maria Claret, Barcelona, Spain
| | - Isabella Annesi-Maesano
- Institute Desbrest of Epidemiology and Public Health, University of Montpellier and INSERM, Montpellier, France
| | - Lorenzo Cecchi
- Centre of Bioclimatology, University of Florence, Florence, Italy
| | - Benedetta Biagioni
- Allergy and Clinical Immunology Unit, San Giovanni di Dio Hospital, Florence, Italy
| | | | - Gennaro D'Amato
- Respiratory Disease Department, Hospital Cardarelli, Naples, Italy
- Medical School of Respiratory Allergy, University of Naples Federico II, Naples, Italy
| | - Athanasios Damialis
- Department of Ecology, School of Biology, Faculty of Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stefano Del Giacco
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy
| | - Leticia De Las Vecillas
- Department of Allergy, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Javier Dominguez-Ortega
- Department of Allergy, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Carmen Galàn
- Department of Botany, Ecology and Plant Physiology, International Campus of Excellence on Agrifood (ceiA3), University of Córdoba, Córdoba, Spain
| | - Stefanie Gilles
- Environmental Medicine, Faculty of Medicine, University of Augsburg, Augsburg, Germany
| | - Mattia Giovannini
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Stephen Holgate
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Mohamed Jeebhay
- Occupational Medicine Division and Centre for Environmental & Occupational Health Research, University of Cape Town, Cape Town, South Africa
| | - Kari Nadeau
- Department of Environmental Health, Center for Climate, Health, and the Global Environment, Climate and Population Studies, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Nikolaos Papadopoulos
- Allergy and Clinical Immunology Unit, Second Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
- University of Manchester, Manchester, UK
| | - Santiago Quirce
- Department of Allergy, Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Joaquin Sastre
- Allergy Service, Fundación Jiménez Díaz, Faculty of Medicine Universidad Autónoma de Madrid and CIBERES, Instituto Carlos III, Ministry of Science and Innovation, Madrid, Spain
| | - Claudia Traidl-Hoffmann
- Department of Environmental Medicine, Faculty of Medicine, University of Augsburg, Augsburg, Germany
- Institute of Environmental Medicine, Helmholtz Center Munich -German Research Center for Environmental Health, Augsburg, Germany
- Christine Kühne Center for Allergy Research and Education, Davos, Switzerland
| | - Jolanta Walusiak-Skorupa
- Department of Occupational Diseases and Environmental Health, Nofer Institute of Occupational Medicine, Lodz, Poland
| | - Bernardo Sousa-Pinto
- MEDCIDS - Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Josefina Salazar
- Institut de Recerca Sant Pau (IR SANT PAU), Barcelona, Spain
- Centro Cochrane Iberoamericano, Sant Antoni Maria Claret, Barcelona, Spain
| | - L Yesenia Rodríguez-Tanta
- Institut de Recerca Sant Pau (IR SANT PAU), Barcelona, Spain
- Centro Cochrane Iberoamericano, Sant Antoni Maria Claret, Barcelona, Spain
| | - Yahveth Cantero
- Institut de Recerca Sant Pau (IR SANT PAU), Barcelona, Spain
- Centro Cochrane Iberoamericano, Sant Antoni Maria Claret, Barcelona, Spain
| | - Camila Montesinos-Guevara
- Institut de Recerca Sant Pau (IR SANT PAU), Barcelona, Spain
- Centro Cochrane Iberoamericano, Sant Antoni Maria Claret, Barcelona, Spain
- Centro de Investigación en Salud Pública y Epidemiología Clínica (CISPEC), Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Quito, Ecuador
| | - Yang Song
- Institut de Recerca Sant Pau (IR SANT PAU), Barcelona, Spain
- Centro Cochrane Iberoamericano, Sant Antoni Maria Claret, Barcelona, Spain
| | - Giancarlo Alvarado-Gamarra
- Institut de Recerca Sant Pau (IR SANT PAU), Barcelona, Spain
- Centro Cochrane Iberoamericano, Sant Antoni Maria Claret, Barcelona, Spain
| | - Ivan Sola
- Institut de Recerca Sant Pau (IR SANT PAU), Barcelona, Spain
- Centro Cochrane Iberoamericano, Sant Antoni Maria Claret, Barcelona, Spain
| | - Pablo Alonso-Coello
- Institut de Recerca Sant Pau (IR SANT PAU), Barcelona, Spain
- Centro Cochrane Iberoamericano, Sant Antoni Maria Claret, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Wendy Nieto-Gutierrez
- Institut de Recerca Sant Pau (IR SANT PAU), Barcelona, Spain
- Centro Cochrane Iberoamericano, Sant Antoni Maria Claret, Barcelona, Spain
| | - Marek Jutel
- Department of Clinical Immunology, Wrocław Medical University, and ALL-MED Medical Research Institute, Wroclaw, Poland
| | - Cezmi A Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University Zurich, Davos, Switzerland
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Min G, Shin J, Kim D, Choe Y, Woo J, Choi KY, Lee J, Cho M, Lee J, Ra JS, Yang W. Potential health risks to disinfection workers from exposure to active substances in COVID-19 biocidal products. Heliyon 2024; 10:e28249. [PMID: 38596037 PMCID: PMC11002044 DOI: 10.1016/j.heliyon.2024.e28249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 03/14/2024] [Accepted: 03/14/2024] [Indexed: 04/11/2024] Open
Abstract
The importance of disinfection has recently been emphasized due to the increasing risk of the spread of infections such as coronavirus disease-2019 (COVID-19). In addition, disinfection for preventing the spread of COVID-19 is highly recommended. The increased use of biocidal products raises concerns regarding the potential health risks from exposure among disinfection workers. This study aimed to assess these exposure and health risks using questionnaires targeting disinfection workers who were exposed to the active substances in biocidal products used for disinfection during the COVID-19 pandemic. A follow-up survey was conducted among 271 disinfection workers for 10 working days within two weeks, and exposure factors with reference to disinfection were evaluated through interview-administered questionnaires. An exposure algorithm was used to evaluate the exposure of disinfection workers during disinfection. The hazard index (HI) was calculated by dividing the inhalation concentration obtained using the exposure algorithm and the dermal dose according to occupational exposure limits (OEL). A sensitivity analysis was conducted to identify the exposure factors with the greatest impact on the inhalation and dermal exposure algorithms. A logistic regression analysis was performed to verify the relationship with health effects and sociodemographic and exposure characteristics. The average number of disinfections performed during 10 working days was 17.5 ± 12.3 times. The type of disinfection work was divided into 2806 cases of COVID-19 prevention and disinfection and 1956 cases of regular pesticide application to prevent and remove any pests. The HI was ≥1, indicating a potential health risk, with the use of ethanol (6.50E+00), quaternary ammonium compounds (QACs; 1.49E+01), and benzalkonium chloride (BKC; 1.73E+00). Dermal exposure was more hazardous than inhalation exposure for 6 of the 11 active substances in biocidal products. The weight fraction and exposure time were the factors that most significantly influenced the inhalation and dermal exposure algorithms in the sensitivity analysis. Higher exposure concentrations were more likely to affect health (AOR: 3.239, 95% CI: 1.155-9.082). This study provides valuable information regarding the exposure and risk of disinfection workers to 11 biocidal active substances included in common disinfectants. Our results suggest that the use of ethanol, BKC, and QACs has potential health risks to disinfection workers, with a higher possibility of negative health impacts with increasing exposure concentration.
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Affiliation(s)
- Gihong Min
- Department of Health and Safety, Daegu Catholic University, Gyeongbuk, South Korea
| | - Jihun Shin
- Department of Health and Safety, Daegu Catholic University, Gyeongbuk, South Korea
| | - Dongjun Kim
- Department of Health and Safety, Daegu Catholic University, Gyeongbuk, South Korea
| | - Youngtae Choe
- Department of Health and Safety, Daegu Catholic University, Gyeongbuk, South Korea
| | - Jaemin Woo
- Department of Health and Safety, Daegu Catholic University, Gyeongbuk, South Korea
| | - Kil Yong Choi
- Department of Environmental Energy Engineering, Anyang University, Anyang, South Korea
| | - Jangwoo Lee
- Convergence Research Center for Big-data, Cheminet Ltd, Seoul, South Korea
| | - Mansu Cho
- Department of Health and Safety, Daegu Catholic University, Gyeongbuk, South Korea
| | - Jongdae Lee
- Department of Environmental Health Science, Soonchunhyang University, Chungnam, South Korea
| | - Jin-Sung Ra
- Eco-testing & Risk Assessment Center, Korea Institute of Industrial Technology, Ansan, South Korea
| | - Wonho Yang
- Department of Health and Safety, Daegu Catholic University, Gyeongbuk, South Korea
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Patel J, Gimeno Ruiz de Porras D, Mitchell LE, Carson A, Whitehead LW, Han I, Pompeii L, Conway S, Zock JP, Henneberger PK, Patel R, De Los Reyes J, Delclos GL. Cleaning Tasks and Products and Asthma Among Health Care Professionals. J Occup Environ Med 2024; 66:28-34. [PMID: 37801602 PMCID: PMC10841035 DOI: 10.1097/jom.0000000000002990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2023]
Abstract
OBJECTIVE Health care workers are at risk for work-related asthma, which may be affected by changes in cleaning practices. We examined associations of cleaning tasks and products with work-related asthma in health care workers in 2016, comparing them with prior results from 2003. METHODS We estimated asthma prevalence by professional group and explored associations of self-reported asthma with job-exposure matrix-based cleaning tasks/products in a representative Texas sample of 9914 physicians, nurses, respiratory/occupational therapists, and nurse aides. RESULTS Response rate was 34.8% (n = 2421). The weighted prevalence rates of physician-diagnosed (15.3%), work-exacerbated (4.1%), and new-onset asthma (6.7%) and bronchial hyperresponsiveness symptoms (31.1%) were similar to 2003. New-onset asthma was associated with building surface cleaning (odds ratio [OR], 1.91; 95% confidence interval [CI], 1.10-3.33), use of ortho-phthalaldehyde (OR, 1.77; 95% CI, 1.15-2.72), bleach/quaternary compounds (OR, 1.91; 95% CI, 1.10-3.33), and sprays (OR, 1.97; 95% CI, 1.12-3.47). CONCLUSION Prevalence of asthma/bronchial hyperresponsiveness seems unchanged, whereas associations of new-onset asthma with exposures to surface cleaning remained, and decreased for instrument cleaning.
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Affiliation(s)
- Jenil Patel
- Southwest Center for Occupational and Environmental Health, Department of Epidemiology, Human Genetics and Environmental Sciences, The University of Texas Health Science Center at Houston (UTHealth Houston) School of Public Health, Houston, TX, USA
- Center for Pediatric Population Health, Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston (UTHealth Houston), Dallas, TX, USA
| | - David Gimeno Ruiz de Porras
- Southwest Center for Occupational and Environmental Health, Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health in San Antonio, The University of Texas Health Science Center at Houston (UTHealth Houston), San Antonio, TX, USA
- Center for Research in Occupational Health, Universitat Pompeu Fabra, Barcelona, Spain
- CIBER Epidemiología y Salud Pública, Madrid, Spain
| | - Laura E. Mitchell
- Department of Epidemiology, Human Genetics and Environmental Sciences, The University of Texas Health Science Center at Houston (UTHealth Houston) School of Public Health, Houston, TX, USA
| | - Arch Carson
- Southwest Center for Occupational and Environmental Health, Department of Epidemiology, Human Genetics and Environmental Sciences, The University of Texas Health Science Center at Houston (UTHealth Houston) School of Public Health, Houston, TX, USA
| | - Lawrence W. Whitehead
- Southwest Center for Occupational and Environmental Health, Department of Epidemiology, Human Genetics and Environmental Sciences, The University of Texas Health Science Center at Houston (UTHealth Houston) School of Public Health, Houston, TX, USA
| | - Inkyu Han
- Department of Epidemiology and Biostatistics, Temple University College of Public Health, Philadelphia, PA, USA
| | - Lisa Pompeii
- Research in Patient Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | | | - Jan-Paul Zock
- Center for Research in Environmental Epidemiology (CREAL), Barcelona, Spain
| | - Paul K. Henneberger
- Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV, USA
| | - Riddhi Patel
- Department of Epidemiology, Human Genetics and Environmental Sciences, The University of Texas Health Science Center at Houston (UTHealth Houston) School of Public Health, Houston, TX, USA
| | - Joy De Los Reyes
- Department of Biostatistics and Data Science, The University of Texas Health Science Center at Houston (UTHealth Houston) School of Public Health, Houston, TX, USA
| | - George L. Delclos
- Southwest Center for Occupational and Environmental Health, Department of Epidemiology, Human Genetics and Environmental Sciences, The University of Texas Health Science Center at Houston (UTHealth Houston) School of Public Health, Houston, TX, USA
- Center for Research in Occupational Health, Universitat Pompeu Fabra, Barcelona, Spain
- CIBER Epidemiología y Salud Pública, Madrid, Spain
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Chiang CE, Li HH, Rowley DD, Fang TP, Lin HL. Influence of Aerosol Mask Design on Fugitive Aerosol Concentrations During Nebulization. Respir Care 2023; 68:1510-1518. [PMID: 37280074 PMCID: PMC10589112 DOI: 10.4187/respcare.10578] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Secondhand exposure to fugitive aerosols may cause airway diseases in health providers. We hypothesized that redesigning aerosol masks to be closed-featured would reduce the fugitive aerosol concentrations during nebulization. This study aimed to evaluate the influence of a mask designed for a jet nebulizer on the concentration of fugitive aerosols and delivered doses. METHODS An adult intubation manikin was attached to a lung simulator to mimic normal and distressed adult breathing patterns. The jet nebulizer delivered salbutamol as an aerosol tracer. The nebulizer was attached to 3 aerosol face masks: an aerosol mask, a modified non-rebreathing mask (NRM, with no vent holes), and an AerosoLess mask. An aerosol particle sizer measured aerosol concentrations at parallel distances of 0.8 m and 2.2 m and a frontal distance of 1.8 m from the manikin. The drug dose delivered distal to the manikin's airway was collected, eluted, and analyzed using a spectrophotometer at a 276 nm wavelength. RESULTS With a normal breathing pattern, the trends of aerosol concentrations were higher with an NRM followed by an aerosol mask and AerosoLess mask (P < .001) at 0.8 m; however, the concentrations were higher with an aerosol mask followed by NRM and AerosoLess mask at 1.8 m (P < .001) and 2.2 m (P < .001). With a distressed breathing pattern, the aerosol concentrations were higher with an aerosol mask followed by an NRM and AerosoLess mask at 0.8 m, 1.8 m (P < .001), and 2.2 m (P = .005). The delivered drug dose was significantly higher with AerosoLess mask with a normal breathing pattern and with an aerosol mask with a distressed breathing pattern. CONCLUSIONS Mask design influences fugitive aerosol concentrations in the environment, and a filtered mask reduces the concentration of aerosols at 3 different distances and with 2 breathing patterns.
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Affiliation(s)
- Chen-En Chiang
- Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan
| | - Hsin-Hsien Li
- Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan
| | - Daniel D Rowley
- Department of Respiratory Therapy, University of Virginia Medical Center, Charlottesville, Virginia
| | - Tien-Pei Fang
- Department of Respiratory Care, Chang Gung University of Technology and Science, Chiayi, Taiwan; and Department of Respiratory Therapy, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Hui-Ling Lin
- Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan; Department of Respiratory Care, Chang Gung University of Technology and Science, Chiayi, Taiwan; and Department of Respiratory Therapy, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan.
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Wilson AM, Ogunseye OO, Fingesi T, McClelland DJ, Gerald LB, Harber P, Beamer PI, Jones RM. Exposure frequency, intensity, and duration: What we know about work-related asthma risks for healthcare workers from cleaning and disinfection. JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 2023; 20:350-363. [PMID: 37279493 PMCID: PMC10696642 DOI: 10.1080/15459624.2023.2221712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The objective of this review was to scope the current evidence base related to three exposure assessment concepts: frequency, intensity, and duration (latency) for cleaning and disinfection exposures in healthcare and subsequent work-related asthma risks. A search strategy was developed addressing intersections of four main concepts: (1) work-related asthma; (2) occupation (healthcare workers/nurses); (3) cleaning and disinfection; and (4) exposure. Three databases were searched: Embase, PubMed, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) database. Data were extracted related to three main components of risk assessment: (1) exposure frequency, (2) exposure intensity, and (3) exposure duration. Latency data were analyzed using an exponential distribution fit, and extracted concentration data were compared to occupational exposure limits. The final number of included sources from which data were extracted was 133. Latency periods for occupational asthma were exponentially distributed, with a mean waiting time (1/λ) of 4.55 years. No extracted concentration data were above OELs except for some formaldehyde and glutaraldehyde concentrations. Data from included sources also indicated some evidence for a dose-response relationship regarding increased frequency yielding increased risk, but this relationship is unclear due to potential confounders (differences in role/task and associated exposure) and the healthy worker effect. Data priority needs to include linking concentration data to health outcomes, as most current literature does not include both types of measurements in a single study, leading to uncertainty in dose-response relationships.
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Affiliation(s)
- Amanda M. Wilson
- Department of Community, Environment, & Policy, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
| | - Olusola O. Ogunseye
- Department of Community, Environment, & Policy, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
| | - Tina Fingesi
- Department of Community, Environment, & Policy, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
| | | | - Lynn B. Gerald
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
| | - Philip Harber
- Department of Community, Environment, & Policy, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
| | - Paloma I. Beamer
- Department of Community, Environment, & Policy, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
| | - Rachael M. Jones
- Department of Environmental Health Sciences, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
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7
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Blackley BH, Nett RJ, Cox-Ganser JM, Harvey RR, Virji MA. Eye and airway symptoms in hospital staff exposed to a product containing hydrogen peroxide, peracetic acid, and acetic acid. Am J Ind Med 2023; 66:655-669. [PMID: 37221450 PMCID: PMC10431326 DOI: 10.1002/ajim.23488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/10/2023] [Accepted: 05/10/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND Sporicidal products containing hydrogen peroxide (HP), peracetic acid (PAA), and acetic acid (AA) are used widely in multiple industries, including healthcare. Despite widespread use in healthcare, few studies have assessed associations between exposures to HP, PAA, and AA, and work-related symptoms in these settings. METHODS In 2018, we performed a health and exposure assessment at a hospital where a sporicidal product consisting of HP, PAA, and AA, was used as the primary cleaner on hospital surfaces. We collected 56 personal and mobile air samples for HP, PAA, and AA on participants while they performed their regular cleaning duties; collected area samples for HP (n = 28), PAA (n = 28), and AA (n = 70) in multiple hospital locations where cleaning was performed; and administered a postshift survey to assess eye, skin, and upper and lower airway symptoms that occurred cross-shift or in the previous 4 weeks. RESULTS Full-shift exposure levels for HP (range: <3-559 ppb), PAA (range: <0.2-8 ppb), and AA (range: <5-915 ppb) were all below US occupational exposure limits. We observed positive associations (p < 0.05) between shift, departmental average, and departmental 95th percentile exposures to HP, PAA, and AA vapors, and work-related acute (cross-shift) and chronic (previous 4 weeks) eye, upper airway, and lower airway symptoms after adjusting for age, gender, smoking status, use of other cleaning products containing sensitizers and irritants, allergic status, and stress. CONCLUSIONS Our observations of work-related upper and lower airway symptoms among hospital workers exposed to vapors from a sporicidal product containing HP, PAA, and AA indicate a need for a combination of engineering, administrative, and PPE controls to reduce exposure. Additionally, alternative nonchemical disinfection technologies should be further investigated as a means to simultaneously reduce healthcare workers' exposure to disinfectants while also minimizing costly healthcare-acquired infections.
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Affiliation(s)
- Brie Hawley Blackley
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, West Virginia, USA
| | - Randall J. Nett
- Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Fort Collins, Colorado, USA
| | - Jean M. Cox-Ganser
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, West Virginia, USA
| | - Robert Reid Harvey
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, West Virginia, USA
| | - Mohammed Abbas Virji
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, West Virginia, USA
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8
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Mwanga HH, Baatjies R, Jeebhay MF. Occupational risk factors and exposure-response relationships for airway disease among health workers exposed to cleaning agents in tertiary hospitals. Occup Environ Med 2023; 80:361-371. [PMID: 37137692 DOI: 10.1136/oemed-2022-108763] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 04/20/2023] [Indexed: 05/05/2023]
Abstract
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.
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Affiliation(s)
- Hussein H Mwanga
- Division of Occupational Medicine and Centre for Environmental & Occupational Health Research, School of Public Health, University of Cape Town, Cape Town, South Africa
- Department of Environmental and Occupational Health, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | - Roslynn Baatjies
- Division of Occupational Medicine and Centre for Environmental & Occupational Health Research, School of Public Health, University of Cape Town, Cape Town, South Africa
- Department of Environmental and Occupational Studies, Faculty of Applied Sciences, Cape Peninsula University of Technology, Cape Town, Western Cape, South Africa
| | - Mohamed Fareed Jeebhay
- Division of Occupational Medicine and Centre for Environmental & Occupational Health Research, School of Public Health, University of Cape Town, Cape Town, South Africa
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Suleiman AM. Comparison of ConsExpo estimated exposure levels to glycol ethers during professional cleaning work to existing regulatory occupational exposure limit values. INTERNATIONAL JOURNAL OF OCCUPATIONAL SAFETY AND ERGONOMICS 2023; 29:604-612. [PMID: 35363595 DOI: 10.1080/10803548.2022.2061150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Objectives. Researchers have shown that cleaning workers have an increased risk of asthma and rhinitis, mainly due to exposure to chemical substances present in the cleaning products they use. Among the important substances are glycol ethers, increasingly used as components in cleaning products. This study aimed to assess exposure levels of glycol ether in professional cleaning products and compare them to existing regulatory exposure limit values. Methods. Information from safety data sheets of the products is used to identify the glycol ethers present in the cleaning products and their respective concentrations. Other sources were used to obtain the relevant data required for use in the tool to generate exposure assessments. Exposure levels for various cleaning work exposure scenarios were estimated using the ConsExpo Web tool. Results. The estimated exposure values are significantly lower than the existing regulatory occupational exposure limit (OEL) values for the different glycol ethers. Conclusions. The study showed that the risk of exposure to glycol ethers by inhalation from professional cleaning products is minimal as exposure estimates were much below the regulatory OEL values.
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Bozalija A, Maliqi S, Islami P, Iljazi A, Islami H. The Reaction of Airways of Employees Working in the Environments Polluted with Heavy Metals in Mine Kosovo. Toxicol Int 2022. [DOI: 10.18311/ti/2022/v29i3/28705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
This paper is studied the respiratory function as a result of the impact of air pollution in the environment of the sector of exploitation of heavy minerals such Pb, Zn, Au, Ag, Bi, Cd, PM in the mines of Trepça, Kosovo. Lung function parameters are determined by Body plethysmography. Airway resistance (Raw) was recorded and Intra-Thoracic Gas Volume (ITGV) was measured and specific resistance (SRaw) and airway specific conductance (SGaw) were calculated. The research was done in two groups, the control group and the experimental one. The control group consisted of 24 healthy people, while the experimental one is made up of 52 mining workers for the exploitation of minerals in the Trepçamine, Kosovo. The results obtained from this research indicate that the mean value of specific resistance (SRaw) is significantly higher in the experimental group (p<0.01), compared to the control group (p>0.1). Also, in this study it was confirmed that smoking favors the negative effects of air contamination in the mineral exploitation sector, the changes are significant (p<0.01). Respiratory system parameters of the control group and the experimental group were measured before and after bronchoprovocation with histamine-aerosol (1 mg/ml). The differences between these two groups after provocation were statistically significant (p<0.01). Respiratory changes from air pollution with noxae in mines where metals are mined, it takes a long time for changes in respiratory function to appear. Therefore, exposure of workers to these conditions poses a risk to their health, causing bronchial reactivity, bronchial asthma or, obstructive pulmonary syndrome.
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11
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Heibati B, Jaakkola MS, Lajunen TK, Ducatman A, Veysi R, Karimi A, Jaakkola JJK. Do hospital workers experience a higher risk of respiratory symptoms and loss of lung function? BMC Pulm Med 2022; 22:303. [PMID: 35941624 PMCID: PMC9358815 DOI: 10.1186/s12890-022-02098-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 07/18/2022] [Indexed: 01/09/2023] Open
Abstract
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.
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Affiliation(s)
- Behzad Heibati
- Faculty of Medicine, Center for Environmental and Respiratory Health Research, University of Oulu, Aapistie 5B, P.O. Box 5000, 90014, Oulu, Finland.,Faculty of Medicine, Biocenter Oulu, University of Oulu, P.O. Box 5000, 90014, Oulu, Finland.,Medical Research Center Oulu, Oulu University Hospital, University of Oulu, P.O. Box 8000, 90014, Oulu, Finland
| | - Maritta S Jaakkola
- Faculty of Medicine, Center for Environmental and Respiratory Health Research, University of Oulu, Aapistie 5B, P.O. Box 5000, 90014, Oulu, Finland.,Faculty of Medicine, Biocenter Oulu, University of Oulu, P.O. Box 5000, 90014, Oulu, Finland.,Medical Research Center Oulu, Oulu University Hospital, University of Oulu, P.O. Box 8000, 90014, Oulu, Finland
| | - Taina K Lajunen
- Faculty of Medicine, Center for Environmental and Respiratory Health Research, University of Oulu, Aapistie 5B, P.O. Box 5000, 90014, Oulu, Finland.,Faculty of Medicine, Biocenter Oulu, University of Oulu, P.O. Box 5000, 90014, Oulu, Finland.,Medical Research Center Oulu, Oulu University Hospital, University of Oulu, P.O. Box 8000, 90014, Oulu, Finland
| | - Alan Ducatman
- West Virginia University School of Public Health, Morgantown, WV, USA
| | - Rahmat Veysi
- Department of Occupational Health Engineering, School of Public Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Karimi
- Department of Occupational Health, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
| | - Jouni J K Jaakkola
- Faculty of Medicine, Center for Environmental and Respiratory Health Research, University of Oulu, Aapistie 5B, P.O. Box 5000, 90014, Oulu, Finland. .,Faculty of Medicine, Biocenter Oulu, University of Oulu, P.O. Box 5000, 90014, Oulu, Finland. .,Medical Research Center Oulu, Oulu University Hospital, University of Oulu, P.O. Box 8000, 90014, Oulu, Finland. .,Finnish Meteorological Institute, P.O. Box 503, 00101, Helsinki, Finland.
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Pacheco Da Silva E, Sit G, Goldberg M, Leynaert B, Nadif R, Ribet C, Roche N, Zins M, Varraso R, Dumas O, Le Moual N. Household use of green and homemade cleaning products, wipe application mode, and asthma among French adults from the CONSTANCES cohort. INDOOR AIR 2022; 32:e13078. [PMID: 35904383 PMCID: PMC9545541 DOI: 10.1111/ina.13078] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 06/13/2022] [Accepted: 06/30/2022] [Indexed: 06/15/2023]
Abstract
While exposure to irritant and sprayed cleaning products at home is known to have a harmful role in asthma, the potential health effect of other categories or forms has not been investigated. We studied the associations of household use of cleaning products, including green, homemade products, and disinfecting wipes, with asthma based on data from the large French population-based CONSTANCES cohort. Participants completed standardized questionnaires on respiratory health and household use of cleaning products. Cross-sectional associations of cleaning products with current asthma, adjusted for gender, age, smoking status, BMI, and educational level, were evaluated by logistic regressions. Analyses were conducted in 41 570 participants (mean age: 47 years, 56% women, weekly use of the six specific products/forms studied varied from 11% to 37%). Weekly use of irritants (OR = 1.23 [1.13-1.35]), scented (OR = 1.15 [1.06-1.26]), green (OR = 1.09 [1.00-1.20]), and homemade products (OR = 1.19 [1.06-1.34]), as well as sprays (OR = 1.18 [1.08-1.29]), disinfecting wipes (OR = 1.21 [1.09-1.34]) were significantly associated with asthma, with significant trends according to the frequency of use. When they were not co-used with irritants/sprays, associations were reduced and persisted only for disinfecting wipes. Weekly use of disinfecting wipes at home was associated with current asthma, but fewer risks were observed for the use of green and homemade products.
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Affiliation(s)
- Emilie Pacheco Da Silva
- Université Paris‐Saclay, UVSQ, Univ. Paris‐Sud, InsermÉquipe d'Épidémiologie Respiratoire Intégrative, CESPVillejuifFrance
| | - Guillaume Sit
- Université Paris‐Saclay, UVSQ, Univ. Paris‐Sud, InsermÉquipe d'Épidémiologie Respiratoire Intégrative, CESPVillejuifFrance
| | - Marcel Goldberg
- Université de Paris, Unité "Cohortes en Population" INSERMUniversité Paris Saclay, UVSQ, UMSParisFrance
| | - Bénédicte Leynaert
- Université Paris‐Saclay, UVSQ, Univ. Paris‐Sud, InsermÉquipe d'Épidémiologie Respiratoire Intégrative, CESPVillejuifFrance
| | - Rachel Nadif
- Université Paris‐Saclay, UVSQ, Univ. Paris‐Sud, InsermÉquipe d'Épidémiologie Respiratoire Intégrative, CESPVillejuifFrance
| | - Céline Ribet
- Université de Paris, Unité "Cohortes en Population" INSERMUniversité Paris Saclay, UVSQ, UMSParisFrance
| | - Nicolas Roche
- Pneumologie, Hôpital CochinAPHP.Centre – Université de ParisParisFrance
| | - Marie Zins
- Université de Paris, Unité "Cohortes en Population" INSERMUniversité Paris Saclay, UVSQ, UMSParisFrance
| | - Raphaëlle Varraso
- Université Paris‐Saclay, UVSQ, Univ. Paris‐Sud, InsermÉquipe d'Épidémiologie Respiratoire Intégrative, CESPVillejuifFrance
| | - Orianne Dumas
- Université Paris‐Saclay, UVSQ, Univ. Paris‐Sud, InsermÉquipe d'Épidémiologie Respiratoire Intégrative, CESPVillejuifFrance
| | - Nicole Le Moual
- Université Paris‐Saclay, UVSQ, Univ. Paris‐Sud, InsermÉquipe d'Épidémiologie Respiratoire Intégrative, CESPVillejuifFrance
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Dang KTL, Garrido AN, Prasad S, Afanasyeva M, Lipszyc JC, Orchanian‐Cheff A, Tarlo SM. The relationship between cleaning product exposure and respiratory and skin symptoms among healthcare workers in a hospital setting: A systematic review and meta‐analysis. Health Sci Rep 2022; 5:e623. [PMID: 35509379 PMCID: PMC9059197 DOI: 10.1002/hsr2.623] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 03/17/2022] [Accepted: 03/28/2022] [Indexed: 11/12/2022] Open
Abstract
Background and Aims Several studies from multiple work settings have reported an increase in asthma and asthma‐like respiratory symptoms in workers exposed to cleaning or disinfecting agents. Hospital workers perform many cleaning and disinfecting activities and may be vulnerable to respiratory and skin symptoms caused by these agents. This systematic review and meta‐analysis aim to quantify the risk of asthma and asthma‐like symptoms in hospital workers exposed to cleaning/disinfecting agents. A secondary aim is to assess associated risks of skin symptoms in those studies. Methods MEDLINE, EMBASE, CDSR, CENTRAL, CINAHL databases, and references of relevant review articles were searched. NHLBI quality assessment tools were used to assess the quality of the included studies. A total of 2550 articles were retrieved and 34 studies met criteria to be included. The software R version 4.0.5 was used to perform the meta‐analysis. The random‐effects model was used to pool the results due to within‐studies heterogeneity. Results Meta‐analysis of 10 studies evaluating the association between occupational cleaning exposures and asthma demonstrated a 35% increased risk in exposed hospital workers (meta‐RR = 1.35, 95% CI: 1.09–1.68). The risk of asthma increased when workers were exposed to bleach compared with nonexposed workers (meta‐RR = 1.51, 95% CI: 0.54–4.18), but was not statistically significant. Two studies investigated the relationship between respiratory and skin symptoms and produced mixed results. Conclusions The results suggest a need for preventive practices to reduce the risk of asthma and asthma‐like symptoms in hospital workers exposed to occupational cleaning/disinfecting agents. Trial registration number: CRD42020137804.
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Affiliation(s)
- Kelly T. L. Dang
- Departments of Medicine University of Toronto Toronto Ontario Canada
| | - Ameth N. Garrido
- Departments of Medicine University of Toronto Toronto Ontario Canada
- Departments of Medicine University of Toronto Institute for Medical Sciences Toronto Ontario Canada
- Toronto, Departments of Medicine University Health Network Toronto Ontario Canada
| | - Shivonne Prasad
- Monash University School of Public Health and Preventive Medicine Melbourne Victoria Australia
| | - Marina Afanasyeva
- Departments of Medicine Humber River Hospital, Toronto Toronto Ontario Canada
- Dalla Lana School of Public Health University of Toronto Toronto Ontario Canada
| | - Joshua C. Lipszyc
- Departments of Medicine University of Toronto Toronto Ontario Canada
| | - Ani Orchanian‐Cheff
- Toronto, Departments of Medicine University Health Network Toronto Ontario Canada
| | - Susan M. Tarlo
- Departments of Medicine University of Toronto Toronto Ontario Canada
- Departments of Medicine University of Toronto Institute for Medical Sciences Toronto Ontario Canada
- Toronto, Departments of Medicine University Health Network Toronto Ontario Canada
- Dalla Lana School of Public Health University of Toronto Toronto Ontario Canada
- St Michael's Hospital Toronto Ontario Canada
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Environmental Injustice and Industrial Chicken Farming in Maryland. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182111039. [PMID: 34769558 PMCID: PMC8582720 DOI: 10.3390/ijerph182111039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/05/2021] [Accepted: 10/13/2021] [Indexed: 12/01/2022]
Abstract
Maryland’s growing chicken industry, including concentrated animal feeding operations (CAFOs) and meat processing plants, raises a number of concerns regarding public health and environmental justice. Using hot spot analysis, we analyzed the totality of Maryland’s CAFOs and meat processing plants and those restricted to the Eastern Shore to assess whether communities of color and/or low socioeconomic status communities disproportionately hosted these types of facilities at the census tract level. We used zero-inflated regression modeling to determine the strength of the associations between environmental justice variables and the location of CAFOs and meatpacking facilities at the State level and on the Eastern Shore. Hot spot analyses demonstrated that CAFO hot spots on the Eastern Shore were located in counties with some of the lowest wealth in the State, including the lowest ranking county—Somerset. Zero-inflated regression models demonstrated that increases in median household income across the state were associated with a 0.04-unit reduction in CAFOs. For every unit increase in the percentage of people of color (POC), there was a 0.02-unit increase in meat processing facilities across the state. The distribution of CAFOs and meat processing plants across Maryland may contribute to poor health outcomes in areas affected by such production, and contribute to health disparities and health inequity.
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Mwanga HH, Baatjies R, Singh T, Jeebhay MF. Asthma Phenotypes and Host Risk Factors Associated With Various Asthma-Related Outcomes in Health Workers. FRONTIERS IN ALLERGY 2021; 2:747566. [PMID: 35386991 PMCID: PMC8974710 DOI: 10.3389/falgy.2021.747566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 09/21/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Work-related asthma phenotypes in health workers (HWs) exposed to cleaning agents have not been investigated extensively as other occupational exposures. This study aimed to describe asthma phenotypes and to identify important host risk factors associated with various asthma-related outcomes. Methods: A cross-sectional study of 699 HWs was conducted in two large tertiary hospitals. A total of 697 HWs completed questionnaire interviews. Sera collected from 682 HWs were analyzed for atopy (Phadiatop) and IgE to occupational allergens (NRL—Hev b5, Hev b6.02; chlorhexidine and ortho-phthalaldehyde—OPA). Methacholine (MCT), bronchodilator challenge (BDR) and fractional exhaled nitric oxide (FeNO) were performed. An asthma symptom score (ASS) used five asthma-related symptoms reported in the past 12 months. Current asthma was based on use of asthma medication or an asthma attack or being woken up by an attack of shortness of breath in the past 12 months. Nonspecific bronchial hyperresponsiveness (NSBH) was defined as having either a positive MCT or a significant bronchodilator response. Two continuous indices of NSBH [continuous index of responsiveness (CIR) and dose-response slope (DRS)] were calculated. Results: The prevalence of current asthma was 10%, atopic asthma (6%) and non-atopic asthma (4%). Overall, 2% of subjects had work-related asthma. There was a weak positive association between NSBH and FeNO [CIR: Beta coefficient (β) = 0.12; CI: 0.03–0.22 and DRS: β = 0.07; CI: 0.03–0.12]. Combining FeNO ≥ 50 ppb with a BDR [mean ratio (MR) = 5.89; CI: 1.02–34.14] or with NSBH (MR = 4.62; CI: 1.16–18.46) correlated better with ASS than FeNO alone (MR = 2.23; CI: 1.30–3.85). HWs with current asthma were twice as likely to be atopic. FeNO was positively associated with atopy (OR = 3.19; CI: 1.59–6.39) but negatively associated with smoking status (GMR = 0.76; CI: 0.62–0.94). Most HWs sensitized to occupational allergens were atopic. Conclusion: Atopic asthma was more prevalent than non-atopic asthma in HWs. Most asthma-related outcomes were positively associated with allergic predictors suggesting a dominant role for IgE mechanisms for work-related symptoms and asthma associated with sensitization to OPA or chlorhexidine.
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Affiliation(s)
- Hussein H. Mwanga
- Division of Occupational Medicine and Center for Environmental & Occupational Health Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Department of Environmental and Occupational Health, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Roslynn Baatjies
- Division of Occupational Medicine and Center for Environmental & Occupational Health Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Department of Environmental and Occupational Studies, Faculty of Applied Sciences, Cape Peninsula University of Technology, Cape Town, South Africa
| | - Tanusha Singh
- National Institute for Occupational Health, National Health Laboratory Services, Johannesburg, South Africa
- Department of Clinical Microbiology and Infectious Diseases, School of Pathology, University of the Witwatersrand, Johannesburg, South Africa
- Department of Environmental Health, Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
| | - Mohamed F. Jeebhay
- Division of Occupational Medicine and Center for Environmental & Occupational Health Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- *Correspondence: Mohamed F. Jeebhay
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Osimitz TG, Droege W. Quaternary ammonium compounds: perspectives on benefits, hazards, and risk. TOXICOLOGY RESEARCH AND APPLICATION 2021. [DOI: 10.1177/23978473211049085] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Quaternary ammonium compounds are antimicrobial chemicals that provide significant public health benefits by controlling bacteria and viruses that cause infections such as colds, flu, and COVID. The benefits of antimicrobial QACs are seen in increased quality-of-life measures, such as reduced time away from work and school and reduced medical costs. As active antimicrobial agents, QACs and QAC-containing consumer and professional products are highly regulated by authorities such as the US Environmental Protection Agency and the European Chemicals Agency. A complete database of guideline safety studies, covering human and environmental health, is available and has been reviewed by multiple regulatory agencies globally. The conclusions of regulatory agencies from these studies indicate no concerns regarding reproductive effects, genotoxicity, carcinogenicity, or other systemic adverse effects. In contrast, some published academic studies provide mixed findings on lipid synthesis, reproductive effects, and asthma. However, many of these studies have been found not to be robust in design and lacked appropriate controls to support conclusions of a clear and direct association with an adverse effect. The hazard data for the QACs show that their primary critical effects are point-of-contact effects such as irritation, which exhibit a threshold and occur in a dose–response manner. This review compares toxicity information for QACs, examines human exposures, and quantifies the risks estimated from QAC product use. QACs are an important cleaning and hygiene tool, and the abundance of safety data generated for them provides assurance they can be safely used in professional and household products.
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Xie W, Dumas O, Varraso R, Boggs KM, Camargo CA, Stokes AC. Association of Occupational Exposure to Inhaled Agents in Operating Rooms With Incidence of Chronic Obstructive Pulmonary Disease Among US Female Nurses. JAMA Netw Open 2021; 4:e2125749. [PMID: 34542617 PMCID: PMC8453320 DOI: 10.1001/jamanetworkopen.2021.25749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
IMPORTANCE Employment in operating rooms (ORs) may involve exposure to several inhaled agents, including surgical smoke and disinfectants, which are associated with adverse respiratory health effects. However, the association of long-term employment in ORs and chronic obstructive pulmonary disease (COPD) remains unknown. OBJECTIVE To examine the association of working in an OR with incidence of COPD among female nurses in the US. DESIGN, SETTING, AND PARTICIPANTS This cohort study used data from the Nurses' Health Study for US female registered nurses who provided information on questionnaires regarding OR employment history in 1984 and job type in 1982 and who had no history of COPD in 1984 (baseline). Data analyses were conducted from April 1, 2020, to January 31, 2021. EXPOSURES Duration of nursing in the OR and job type. MAIN OUTCOMES AND MEASURES The associations of any employment as an OR nurse, duration of employment, and duration and job type with incidence of self-reported, physician-diagnosed COPD. Hazard ratios (HRs) and 95% CIs were estimated using Cox proportional hazards regression models stratified by age and calendar year. Models were adjusted for covariates, with model 1 adjusting for age, model 2 also adjusting for cigarette smoking status and pack-year of smoking, and model 3 also adjusting for race and ethnicity, US Census region, and body mass index. RESULTS Among 75 011 female nurses included in the analyses, the mean (SD) age at baseline was 50.5 (7.2) years; 29% had a history of employment in an OR, and 3% had 15 or more years of OR experience. In model 3, employment in an OR for 15 or more years was associated with a 46% increased risk of developing COPD compared with no history of OR employment (HR, 1.46; 95% CI, 1.10-1.93). Compared with nurses who never worked in an OR and had an administrative or nursing education function or a nonnursing job in 1982, the risk of developing COPD was greater among nurses who provided outpatient care (HR, 1.24; 95% CI, 1.04-1.47) and nurses employed in inpatient units (HR, 1.31; 95% CI, 1.07-1.59) who had no history of OR employment and was 69% greater among nurses with OR experience of 15 years or more (HR, 1.69; 95% CI, 1.25-2.28). CONCLUSIONS AND RELEVANCE In this cohort study, OR employment of 15 years or more was associated with an increased risk of developing COPD among female nurses. Additional studies with more recent and direct environmental monitoring data of multiple occupational exposures are needed to assess the relative role of exposure to surgical smoke and disinfectants in the observed association.
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Affiliation(s)
- Wubin Xie
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts
| | - Orianne Dumas
- Université Paris-Saclay, University Paris-Sud, Inserm, Équipe d’Épidémiologie Respiratoire Intégrative, Villejuif, France
| | - Raphaëlle Varraso
- Université Paris-Saclay, University Paris-Sud, Inserm, Équipe d’Épidémiologie Respiratoire Intégrative, Villejuif, France
| | - Krislyn M. Boggs
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Carlos A. Camargo
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Andrew C. Stokes
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts
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Romero Starke K, Friedrich S, Schubert M, Kämpf D, Girbig M, Pretzsch A, Nienhaus A, Seidler A. Are Healthcare Workers at an Increased Risk for Obstructive Respiratory Diseases Due to Cleaning and Disinfection Agents? A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18105159. [PMID: 34068014 PMCID: PMC8152277 DOI: 10.3390/ijerph18105159] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/06/2021] [Accepted: 05/07/2021] [Indexed: 11/16/2022]
Abstract
Several reviews have reported an increased risk of obstructive respiratory diseases in workers exposed to cleaning or disinfection agents, but they have focused mainly on professional cleaners. Cleaning and disinfecting are frequently performed activities by healthcare workers. We conducted a systematic review with meta-analysis to quantify the risk of obstructive respiratory diseases in healthcare workers exposed to cleaning and disinfection agents. We searched the Medline and Embase databases until 4 February 2021 to find adequate primary studies. Two independent reviewers screened the titles/abstracts and the full texts of the studies, as well as performing data extraction and quality assessment. The literature search yielded 9432 records, and 8 studies were found through a hand search. After screening, 14 studies were included in the review. All had a high risk of bias, and most studies dealt with nurses, asthma, and hyperresponsiveness (BHR)-related symptoms. Only one study investigated COPD. The meta-analysis estimated an increased risk of new-onset asthma for nurses (Effect size (ES) = 1.67; 95% CI 1.11–2.50) compared with other occupations and found an increase in the risk of new-onset asthma for nurses exposed to cleaning and disinfecting surfaces (ES = 1.43; 95% CI 1.09–1.89) and instruments (ES = 1.34; 95% CI 1.09–1.65). Exposure to specific chemicals such as bleach and glutaraldehyde (GA) increased the risk of asthma in nurses (bleach ES = 2.44; 95% CI 1.56–3.82; GA ES = 1.91, 95% CI 1.35–2.70). A higher risk for BHR-related symptoms was observed for nurses exposed to cleaning surfaces (ES = 1.44; 95% CI 1.18–1.78). Although the overall evidence was rated as low, the limitations found in this review hint at a potential underestimation of the real risk. These findings highlight the need for reinforced prevention practices with regard to healthcare workers. Similar research investigating these associations among other healthcare workers such as rescue service and nursing home personnel is needed.
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Affiliation(s)
- Karla Romero Starke
- Institute and Policlinic of Occupational and Social Medicine (IPAS), Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany; (S.F.); (M.S.); (D.K.); (M.G.); (A.P.); (A.S.)
- Institute of Sociology, Faculty of Behavioral and Social Sciences, Chemnitz University of Technology, Thüringer Weg 9, 09126 Chemnitz, Germany
- Correspondence:
| | - Sophie Friedrich
- Institute and Policlinic of Occupational and Social Medicine (IPAS), Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany; (S.F.); (M.S.); (D.K.); (M.G.); (A.P.); (A.S.)
| | - Melanie Schubert
- Institute and Policlinic of Occupational and Social Medicine (IPAS), Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany; (S.F.); (M.S.); (D.K.); (M.G.); (A.P.); (A.S.)
| | - Daniel Kämpf
- Institute and Policlinic of Occupational and Social Medicine (IPAS), Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany; (S.F.); (M.S.); (D.K.); (M.G.); (A.P.); (A.S.)
| | - Maria Girbig
- Institute and Policlinic of Occupational and Social Medicine (IPAS), Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany; (S.F.); (M.S.); (D.K.); (M.G.); (A.P.); (A.S.)
| | - Anna Pretzsch
- Institute and Policlinic of Occupational and Social Medicine (IPAS), Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany; (S.F.); (M.S.); (D.K.); (M.G.); (A.P.); (A.S.)
| | - Albert Nienhaus
- Department of Occupational Medicine, Toxic Substances and Health Research, Institution for Statutory Social Accident Insurance and Prevention in the Health Care and Welfare Services (BGW), 22089 Hamburg, Germany;
- Competence Centre for Epidemiology and Health Services Research for Healthcare Professionals (CVcare), Institute for Health Service Research in Dermatology and Nursing (IVDP), University Medical Centre Hamburg-Eppendorf (UKE), 20251 Hamburg, Germany
| | - Andreas Seidler
- Institute and Policlinic of Occupational and Social Medicine (IPAS), Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany; (S.F.); (M.S.); (D.K.); (M.G.); (A.P.); (A.S.)
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Migueres N, Debaille C, Walusiak-Skorupa J, Lipińska-Ojrzanowska A, Munoz X, van Kampen V, Suojalehto H, Suuronen K, Seed M, Lee S, Rifflart C, Godet J, de Blay F, Vandenplas O. Occupational Asthma Caused by Quaternary Ammonium Compounds: A Multicenter Cohort Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3387-3395. [PMID: 33940212 DOI: 10.1016/j.jaip.2021.04.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/11/2021] [Accepted: 04/16/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Quaternary ammonium compounds (QACs) are used extensively for cleaning and disinfection and have been documented in scattered reports as a cause of occupational asthma (OA) through bronchoprovocation tests (BPTs). OBJECTIVE To examine the clinical, functional, and inflammatory profile of QAC-induced OA compared with OA caused by other low-molecular weight (LMW) agents. METHODS The study was conducted in a retrospective multicenter cohort of 871 subjects with OA ascertained by a positive BPT. Subjects with QAC-induced OA (n = 22) were identified based on a positive BPT to QACs after exclusion of those challenged with cleaning products or disinfectants that contained other potential respiratory sensitizers. They were compared with 289 subjects with OA caused by other LMW agents. RESULTS Most subjects with QAC-induced OA were working in the health care sector (n = 14). A twofold or greater increase in the postchallenge level of nonspecific bronchial hyperresponsiveness was recorded in eight of 11 subjects with QAC-induced OA (72.7%) and in 49.7% of those with OA caused by other LMW agents. Although sputum assessment was available in only eight subjects with QAC-induced OA, they showed a significantly greater median (interquartile) increase in sputum eosinophils (18.1% [range, 12.1% to 21.1%]) compared with those with OA caused by other LMW agents (2.0% [range, 0% to 5.2%]; P < .001). CONCLUSIONS This study indicates that QAC-induced OA is associated with a highly eosinophilic pattern of airway response and provides further evidence supporting the sensitizing potential of QACs. The findings highlight the heterogeneous nature of the pathobiologic pathways involved in OA caused by LMW agents.
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Affiliation(s)
- Nicolas Migueres
- Groupe Méthode Recherche Clinique, Pôle de Santé Publique, Strasbourg University, Strasbourg, France; Division of Asthma and Allergy, Department of Chest Diseases, University Hospital of Strasbourg and Fédération de Médecine Translationnelle, Strasbourg University, Strasbourg, France
| | - Charlotte Debaille
- Department of Chest Medicine, Centre Hospitalier Universitaire UCL Namur, Université Catholique de Louvain, Yvoir, Belgium
| | - Jolanta Walusiak-Skorupa
- Department of Occupational Diseases and Environmental Health, Nofer Institute of Occupational Medicine, Lodz, Poland
| | | | - Xavier Munoz
- Servei Pneumologia, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona and CIBER de Enfermedades Respiratorias, Barcelona, Spain
| | - Vera van Kampen
- Institute for Prevention and Occupational Medicine of the German Social Accident Insurance, Ruhr University, Bochum, Germany
| | - Hille Suojalehto
- Occupational Health, Finnish Institute of Occupational Health, Helsinki, Finland
| | - Katri Suuronen
- Occupational Health, Finnish Institute of Occupational Health, Helsinki, Finland
| | - Martin Seed
- Centre for Occupational and Environmental Health, The University of Manchester, Manchester, United Kingdom
| | - Sewon Lee
- Centre for Occupational and Environmental Health, The University of Manchester, Manchester, United Kingdom
| | - Catherine Rifflart
- Department of Chest Medicine, Centre Hospitalier Universitaire UCL Namur, Université Catholique de Louvain, Yvoir, Belgium
| | - Julien Godet
- Groupe Méthode Recherche Clinique, Pôle de Santé Publique, Strasbourg University, Strasbourg, France
| | - Frédéric de Blay
- Division of Asthma and Allergy, Department of Chest Diseases, University Hospital of Strasbourg and Fédération de Médecine Translationnelle, Strasbourg University, Strasbourg, France
| | - Olivier Vandenplas
- Department of Chest Medicine, Centre Hospitalier Universitaire UCL Namur, Université Catholique de Louvain, Yvoir, Belgium.
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20
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Evaluation of Aerosol Therapy during the Escalation of Care in a Model of Adult Cystic Fibrosis. Antibiotics (Basel) 2021; 10:antibiotics10050472. [PMID: 33919035 PMCID: PMC8142975 DOI: 10.3390/antibiotics10050472] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 12/18/2022] Open
Abstract
Lung disease is the main cause of morbidity and mortality in cystic fibrosis (CF). CF patients inhale antibiotics regularly as treatment against persistent bacterial infections. The goal of this study was to investigate the effect of clinical intervention on aerosol therapy during the escalation of care using a bench model of adult CF. Droplet size analysis of selected antibiotics was completed in tandem with the delivered aerosol dose (% of total dose) assessments in simulations of various interventions providing oxygen supplementation or ventilatory support. Results highlight the variability of aerosolised dose delivery. In the homecare setting, the vibrating mesh nebuliser (VMN) delivered significantly more than the jet nebuliser (JN) (16.15 ± 0.86% versus 6.51 ± 2.15%). In the hospital setting, using VMN only, significant variability was seen across clinical interventions. In the emergency department, VMN plus mouthpiece (no supplemental oxygen) was seen to deliver (29.02 ± 1.41%) versus low flow nasal therapy (10 L per minute (LPM) oxygen) (1.81 ± 0.47%) and high flow nasal therapy (50 LPM oxygen) (3.36 ± 0.34%). In the ward/intensive care unit, non-invasive ventilation recorded 19.02 ± 0.28%, versus 22.64 ± 1.88% of the dose delivered during invasive mechanical ventilation. These results will have application in the design of intervention-appropriate aerosol therapy strategies and will be of use to researchers developing new therapeutics for application in cystic fibrosis and beyond.
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21
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Benjamin ML, Arnold S, Rao M, Davis K, Maier A, Virkutyte J. Ventilation and posture effects on inhalation exposures to volatile cleaning ingredients in a simulated domestic worker cleaning environment. INDOOR AIR 2021; 31:128-140. [PMID: 32648981 DOI: 10.1111/ina.12715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 05/13/2020] [Accepted: 07/06/2020] [Indexed: 06/11/2023]
Abstract
Associations between cleaning chemical exposures and asthma have previously been identified in professional cleaners and healthcare workers. Domestic workers, including housecleaners and caregivers, may receive similar exposures but in residential environments with lower ventilation rates. Study objectives were to compare exposures to occupational exposure limits (OELs), to determine relative contributions from individual cleaning tasks to overall exposure, and to evaluate the effects of ventilation and posture on exposure. Airborne chemical concentrations of sprayed cleaning chemicals (acetic acid or ammonia) were measured during typical cleaning tasks in a simulated residential work environment. Whole-house cleaning exposures (18 cleaning tasks) were measured using integrated personal sampling methods. Individual task exposures were measured with a sampling line attached to subjects' breathing zones, with readings recorded by a ppbRAE monitor, equipped with a photoionization detector calibrated for ammonia and acetic acid measurements. Integrated sampling results indicated no exposures above OELs occurred, but 95th percentile air concentrations would require risk management decisions. Exposure reductions were observed with increased source distance, with lower exposures from mopping floors compared to kneeling. Exposure reductions were also observed for most but not all tasks when ventilation was used, with implications that alternative exposure reduction methods may be needed.
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Affiliation(s)
- Michael L Benjamin
- Department of Environmental Health, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Susan Arnold
- Division of Environmental Health Sciences, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Marepalli Rao
- Department of Environmental Health, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kermit Davis
- Department of Environmental Health, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Jurate Virkutyte
- Department of Environmental Health, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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22
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Mac Giolla Eain M, Joyce M, O'Sullivan A, McGrath JA, MacLoughlin R. An in vitro investigation into the release of fugitive medical aerosols into the environment during manual ventilation. J Hosp Infect 2020; 108:135-141. [PMID: 33296706 DOI: 10.1016/j.jhin.2020.11.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND During manual resuscitation, nebulizer therapy may be used to deliver therapeutics to patients in respiratory distress. However, the devices used to generate and deliver these medical aerosols have the potential to release these therapeutics into the local environment and expose caregivers to unwanted medical aerosols. AIM To quantify the levels of fugitive medical aerosol released into the environment during aerosol drug delivery using a manual resuscitation bag with and without filtration. METHODS Time-varying fugitive aerosol concentrations were measured using an aerodynamic particle sizer placed at a position designed to mimic a caregiver. Two nebulizer types were assessed, a vibrating mesh nebulizer and a jet nebulizer. The aerosol dose delivered to the simulated patient lung was also quantified. FINDINGS Filtration of the exhalation port of the manual resuscitation bag was seen to reduce fugitive medical aerosols to ambient levels for both nebulizer types. The vibrating mesh nebulizer delivered the greatest quantity of aerosol to the simulated adult patient (18.44 ± 1.03% versus 3.64 ± 0.26% with a jet nebulizer). CONCLUSIONS The results highlight the potential for exposure to fugitive medical aerosols released during the delivery of aerosol therapy with a manual resuscitation bag and also the potential for significant variation in patient lung dose depending on nebulizer type.
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Affiliation(s)
| | - M Joyce
- Aerogen, IDA Business Park, Dangan, Galway, Ireland
| | - A O'Sullivan
- Aerogen, IDA Business Park, Dangan, Galway, Ireland
| | - J A McGrath
- School of Physics & Ryan Institute's Centre for Climate and Air Pollution Studies, National University of Ireland Galway, Galway, Ireland
| | - R MacLoughlin
- Aerogen, IDA Business Park, Dangan, Galway, Ireland; School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons, Dublin, Ireland; School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland.
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23
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Rai R, El‐Zaemey S, Dorji N, Fritschi L. Occupational exposures to hazardous chemicals and agents among healthcare workers in Bhutan. Am J Ind Med 2020; 63:1109-1115. [PMID: 33047357 DOI: 10.1002/ajim.23192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/16/2020] [Accepted: 09/18/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Occupational exposures to hazardous chemicals among healthcare workers can result in long-term adverse health outcomes. Research on such exposures from low- and middle-income countries is limited. The aim of this study was to estimate the prevalence of exposures to a range of chemicals used in healthcare settings among Bhutanese healthcare workers. METHODS A cross-sectional study was conducted among healthcare workers (n = 370) working in three hospitals in the western region of Bhutan. Demographic and occupational information was collected, and exposures to asthmagens, carcinogens, ototoxic and other agents were assessed using a web-based tool. The prevalence of exposure to these chemicals was calculated and the circumstances resulting in such exposures were examined. RESULTS The prevalence of exposure to one or more asthmagen, carcinogen, and ototoxic agent was 98.7%, 28.1%, and 7.6%, respectively; and was 6.2% for anesthetic gases and 2.2% for antineoplastic drugs. The most common exposures were to latex, and cleaning and disinfecting agents in the asthmagens group; formaldehyde in the carcinogens group; and p-xylene among ototoxic agents. The circumstances resulting in exposures were using latex gloves, using bleach and chlorhexidine for cleaning, using formaldehyde as a disinfectant and in the laboratory, and using p-xylene in the laboratory. CONCLUSIONS The results indicate that a large proportion of Bhutanese healthcare workers are occupationally exposed to chemicals linked to chronic diseases, with exposure prevalence higher than in high-income countries. The study provides information that can be used to formulate policies and to implement control measures to protect healthcare workers.
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Affiliation(s)
- Rajni Rai
- School of Public Health Curtin University Bentley Western Australia Australia
| | - Sonia El‐Zaemey
- School of Public Health Curtin University Bentley Western Australia Australia
| | - Nidup Dorji
- Faculty of Nursing and Public Health Khesar Gyalpo University of Medical Sciences of Bhutan Thimphu Bhutan
| | - Lin Fritschi
- School of Public Health Curtin University Bentley Western Australia Australia
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Archangelidi O, Sathiyajit S, Consonni D, Jarvis D, De Matteis S. Cleaning products and respiratory health outcomes in occupational cleaners: a systematic review and meta-analysis. Occup Environ Med 2020; 78:oemed-2020-106776. [PMID: 33234692 DOI: 10.1136/oemed-2020-106776] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/25/2020] [Accepted: 10/30/2020] [Indexed: 01/07/2023]
Abstract
There is consistent evidence of increased respiratory symptoms in occupational cleaners; however, uncertainty remains on type of respiratory health effects, underlying causal agents, mechanisms and respiratory phenotypes. We aimed to conduct a systematic review and if possible, a meta-analysis of the available literature to characterise and quantify the cleaning-related respiratory health effects. We searched MEDLINE and EMBASE databases and included studies that evaluated the association of any respiratory health outcome with exposure to cleaning occupation or products in occupational cleaners. A modified GRADE was used to appraise the quality of included studies. We retrieved 1124 articles, and after applying our inclusion criteria, 39 were selected for the systematic review. We performed a meta-analysis of the 21 studies evaluating asthma which showed a 50% increased pooled relative risk in cleaners (meta-relative risk (RR)=1.50; 95% CI 1.44 to 1.56). Population-based cross-sectional studies showed more stable associations with asthma risk. No evidence of atopic asthma as dominant phenotype emerged. Also, we estimated a 43% increased risk (meta-RR=1.43; 95% CI 1.31 to 1.56) of chronic obstructive pulmonary disease. Evidence for associations with bronchial-hyper-responsiveness, lung function decline, rhinitis, upper and lower respiratory tract symptoms was weaker. In our systematic review and meta-analysis, we found that working as a cleaner is associated with an increased risk of reversible and even irreversible obstructive airway diseases. All studies lacked quantitative exposure assessment to cleaning products; this would help elucidate underlying causal agents and mechanisms. Exposure control and respiratory surveillance among cleaners is warranted to prevent the associated respiratory health burden. Trial registration number: CRD4201705915.
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Affiliation(s)
| | | | - Dario Consonni
- Epidemiology Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Sara De Matteis
- NHLI, Imperial College London, London, UK
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Sardegna, Italy
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25
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Luz A, DeLeo P, Pechacek N, Freemantle M. Human health hazard assessment of quaternary ammonium compounds: Didecyl dimethyl ammonium chloride and alkyl (C12–C16) dimethyl benzyl ammonium chloride. Regul Toxicol Pharmacol 2020; 116:104717. [DOI: 10.1016/j.yrtph.2020.104717] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 05/29/2020] [Accepted: 06/16/2020] [Indexed: 12/20/2022]
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26
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Chemicals inhaled from spray cleaning and disinfection products and their respiratory effects. A comprehensive review. Int J Hyg Environ Health 2020; 229:113592. [PMID: 32810683 DOI: 10.1016/j.ijheh.2020.113592] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/20/2020] [Accepted: 07/03/2020] [Indexed: 12/13/2022]
Abstract
Spray cleaning and disinfection products have been associated with adverse respiratory effects in professional cleaners and among residents doing domestic cleaning. This review combines information about use of spray products from epidemiological and clinical studies, in vivo and in vitro toxicological studies of cleaning chemicals, as well as human and field exposure studies. The most frequent chemicals in spray cleaning and disinfection products were compiled, based on registrations in the Danish Product Registry. The chemicals were divided into acids, bases, disinfectants, fragrances, organic solvents, propellants, and tensides. In addition, an assessment of selected cleaning and disinfectant chemicals in spray products was carried out. Chemicals of concern regarding respiratory effects (e.g. asthma) are corrosive chemicals such as strong acids and bases (including ammonia and hypochlorite) and quaternary ammonium compounds (QACs). However, the evidence for respiratory effects after inhalation of QACs is ambiguous. Common fragrances are generally not considered to be of concern following inhalation. Solvents including glycols and glycol ethers as well as propellants are generally weak airway irritants and not expected to induce sensitization in the airways. Mixing of certain cleaning products can produce corrosive airborne chemicals. We discuss different hypotheses for the mechanisms behind the development of respiratory effects of inhalation of chemicals in cleaning agents. An integrative assessment is needed to understand how these chemicals can cause the various respiratory effects.
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Brooks C, Slater T, Corbin M, McLean D, Firestone RT, Zock JP, Pearce N, Douwes J. Respiratory health in professional cleaners: Symptoms, lung function, and risk factors. Clin Exp Allergy 2020; 50:567-576. [PMID: 32159892 DOI: 10.1111/cea.13597] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 02/13/2020] [Accepted: 03/08/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cleaning is associated with an increased risk of asthma symptoms, but few studies have measured functional characteristics of airway disease in cleaners. AIMS To assess and characterize respiratory symptoms and lung function in professional cleaners, and determine potential risk factors for adverse respiratory outcomes. METHODS Symptoms, pre-/post-bronchodilator lung function, atopy, and cleaning exposures were assessed in 425 cleaners and 281 reference workers in Wellington, New Zealand between 2008 and 2010. RESULTS Cleaners had an increased risk of current asthma (past 12 months), defined as: woken by shortness of breath, asthma attack, or asthma medication (OR = 1.83, 95% CI = 1.18-2.85). Despite this, they had similar rates of current wheezing (OR = 0.93, 95% CI = 0.65-1.32) and were less likely to have a doctor diagnosis of asthma ever (OR = 0.62, 95% CI = 0.42-0.92). Cleaners overall had lower lung function (FEV1 , FVC; P < .05). Asthma in cleaners was associated with less atopy (OR = 0.35, 95% CI = 0.13-0.90), fewer wheezing attacks (OR = 0.40, 95% CI = 0.17-0.97; >3 vs ≤3 times/year), and reduced bronchodilator response (6% vs 9% mean FEV1 -%-predicted change, P < .05) compared to asthma in reference workers. Cleaning of cafes/restaurants/kitchens and using upholstery sprays or liquid multi-use cleaner was associated with symptoms, whilst several exposures were also associated with lung function deficits (P < .05). CONCLUSIONS AND CLINICAL RELEVANCE Cleaners are at risk of some asthma-associated symptoms and reduced lung function. However, as it was not strongly associated with wheeze and atopy, and airway obstruction was less reversible, asthma in some cleaners may represent a distinct phenotype.
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Affiliation(s)
- Collin Brooks
- Centre for Public Health Research, Massey University, Wellington, New Zealand
| | - Tania Slater
- Centre for Public Health Research, Massey University, Wellington, New Zealand
| | - Marine Corbin
- Centre for Public Health Research, Massey University, Wellington, New Zealand
| | - Dave McLean
- Centre for Public Health Research, Massey University, Wellington, New Zealand
| | | | - Jan-Paul Zock
- ISGlobal, Barcelona, Spain.,Universitat Pompeu Fabra (UPF), Barcelona, Spain.,CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Neil Pearce
- Centre for Public Health Research, Massey University, Wellington, New Zealand.,Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Jeroen Douwes
- Centre for Public Health Research, Massey University, Wellington, New Zealand
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28
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Dumas O, Boggs KM, Quinot C, Varraso R, Zock J, Henneberger PK, Speizer FE, Le Moual N, Camargo CA. Occupational exposure to disinfectants and asthma incidence in U.S. nurses: A prospective cohort study. Am J Ind Med 2020; 63:44-50. [PMID: 31692020 DOI: 10.1002/ajim.23067] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 09/24/2019] [Accepted: 10/18/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Exposure to disinfectants among healthcare workers has been associated with respiratory health effects, in particular, asthma. However, most studies are cross-sectional and the role of disinfectant exposures in asthma development requires longitudinal studies. We investigated the association between occupational exposure to disinfectants and incident asthma in a large cohort of U.S. female nurses. METHODS The Nurses' Health Study II is a prospective cohort of 116 429 female nurses enrolled in 1989. Analyses included 61 539 participants who were still in a nursing job and with no history of asthma in 2009 (baseline; mean age: 55 years). During 277 744 person-years of follow-up (2009-2015), 370 nurses reported incident physician-diagnosed asthma. Occupational exposure was evaluated by questionnaire and a Job-Task-Exposure Matrix (JTEM). We examined the association between disinfectant exposure and subsequent asthma development, adjusted for age, race, ethnicity, smoking status, and body mass index. RESULTS Weekly use of disinfectants to clean surfaces only (23% exposed) or to clean medical instruments (19% exposed) was not associated with incident asthma (adjusted hazard ratio [95% confidence interval] for surfaces, 1.12 [0.87-1.43]; for instruments, 1.13 [0.87-1.48]). No association was observed between high-level exposure to specific disinfectants/cleaning products evaluated by the JTEM (formaldehyde, glutaraldehyde, bleach, hydrogen peroxide, alcohol quats, or enzymatic cleaners) and asthma incidence. CONCLUSIONS In a population of late career nurses, we observed no significant association between exposure to disinfectants and asthma incidence. A potential role of disinfectant exposures in asthma development warrants further study among healthcare workers at earlier career stage to limit the healthy worker effect.
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Affiliation(s)
- Orianne Dumas
- INSERM, U1168, VIMA‐Aging and Chronic DiseasesEpidemiological and Public Health ApproachesVillejuif France
- UMR‐S 1168Univ Versailles St‐Quentin‐en‐YvelinesMontigny le Bretonneux France
| | - Krislyn M. Boggs
- Channing Division of Network Medicine, Department of MedicineBrigham & Women's Hospital and Harvard Medical SchoolBoston Massachusetts
- Department of Emergency MedicineMassachusetts General Hospital and Harvard Medical SchoolBoston Massachusetts
| | - Catherine Quinot
- INSERM, U1168, VIMA‐Aging and Chronic DiseasesEpidemiological and Public Health ApproachesVillejuif France
- UMR‐S 1168Univ Versailles St‐Quentin‐en‐YvelinesMontigny le Bretonneux France
| | - Raphaëlle Varraso
- INSERM, U1168, VIMA‐Aging and Chronic DiseasesEpidemiological and Public Health ApproachesVillejuif France
- UMR‐S 1168Univ Versailles St‐Quentin‐en‐YvelinesMontigny 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 DivisionNational Institute for Occupational Safety and HealthMorgantown West Virginia
| | - Frank E. Speizer
- Channing Division of Network Medicine, Department of MedicineBrigham & Women's Hospital and Harvard Medical SchoolBoston Massachusetts
| | - Nicole Le Moual
- INSERM, U1168, VIMA‐Aging and Chronic DiseasesEpidemiological and Public Health ApproachesVillejuif France
- UMR‐S 1168Univ Versailles St‐Quentin‐en‐YvelinesMontigny le Bretonneux France
| | - Carlos A. Camargo
- Channing Division of Network Medicine, Department of MedicineBrigham & Women's Hospital and Harvard Medical SchoolBoston Massachusetts
- Department of Emergency MedicineMassachusetts General Hospital and Harvard Medical SchoolBoston Massachusetts
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Otter J, Yezli S, Barbut F, Perl T. An overview of automated room disinfection systems: When to use them and how to choose them. DECONTAMINATION IN HOSPITALS AND HEALTHCARE 2020. [PMCID: PMC7153347 DOI: 10.1016/b978-0-08-102565-9.00015-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Conventional disinfection methods are limited by reliance on the operator to ensure appropriate selection, formulation, distribution, and contact time of the agent. Automated room disinfection (ARD) systems remove or reduce reliance on operators and so they have the potential to improve the efficacy of terminal disinfection. The most commonly used systems are hydrogen peroxide vapor (H2O2 vapor), aerosolized hydrogen peroxide (aHP), and ultraviolet (UV) light. These systems have important differences in their active agent, delivery mechanism, efficacy, process time, and ease of use. The choice of ARD system should be influenced by the intended application, the evidence base for effectiveness, practicalities of implementation, and cost considerations.
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Affiliation(s)
- J.A. Otter
- NIHR Health Protection Research Unit (HPRU) in HCAIs and AMR at Imperial College London, and Imperial College Healthcare NHS Trust, Infection Prevention and Control, London, United Kingdom
| | - S. Yezli
- Global Centre for Mass Gatherings Medicine, WHO Collaborating Centre for Mass Gatherings Medicine, Ministry of Health-Public Health Directorate, Riyadh, Kingdom of Saudi Arabia
| | - F. Barbut
- National Reference Laboratory for C. difficile, Infection Control Unit, Hôpital Saint Antoine, Paris, France,INSERM S-1139, Faculté de Pharmacie de Paris, Université de Paris, Paris, France
| | - T.M. Perl
- Infectious Diseases and Geographic Medicine, UT Southwestern Medical Center, Dallas, TX, United States
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Socioeconomic and demographic predictors of high blood pressure, diabetes, asthma and heart disease among adults engaged in various occupations: evidence from India. J Biosoc Sci 2019; 52:629-649. [PMID: 31647045 DOI: 10.1017/s0021932019000671] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In India, non-communicable diseases (NCDs) accounted for nearly 62% of all deaths in 2016. Four NCDs - high blood pressure, diabetes, asthma and heart disease - together accounted for over 34% of these deaths. Using data from two rounds of the India Human Development Surveys (IHDSs), levels and changes in the prevalence rates of the four NCDs (based on diagnosed cases) among adults aged 15-69 years in India between 2004-05 and 2011-12 were examined by socioeconomic and demographic factors and for five broad occupation categories. The socioeconomic and demographic risk factors for each of these NCDs were determined using multiple linear logistic regression analysis of pooled data from two rounds of the IHDS. The results showed that while urban residence, age, female sex and education were associated with higher odds of high blood pressure, diabetes and heart disease, household economic status was associated with higher odds for all four NCDs. Furthermore, increased higher odds of high blood pressure, diabetes and heart disease were found for the legislator/senior official/professional occupation group compared with non-workers. Skilled agricultural/elementary workers had lower odds of high blood pressure, diabetes, asthma and heart disease. Craft/machine-related trade workers had higher odds of high blood pressure and diabetes, and reduced odds of asthma and heart disease. Compared with non-workers, the odds ratios for asthma were lower for all other occupational categories. During the two study decades, the Government of India implemented several programmes designed to improve the health and well-being of its people. However, more focused attention on the adult population is needed, and special attention should be paid to the issue of the occupational health of the working population through the strict implementation of work place safety protocols and the removal of potential health hazards.
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Veysi R, Heibati B, Jahangiri M, Kumar P, Latif MT, Karimi A. Indoor air quality-induced respiratory symptoms of a hospital staff in Iran. ENVIRONMENTAL MONITORING AND ASSESSMENT 2019; 191:50. [PMID: 30612195 DOI: 10.1007/s10661-018-7182-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 12/21/2018] [Indexed: 06/09/2023]
Abstract
The ambient air of hospitals contains a wide range of biological and chemical pollutants. Exposure to these indoor pollutants can be hazardous to the health of hospital staff. This study aims to evaluate the factors affecting indoor air quality and their effect on the respiratory health of staff members in a busy Iranian hospital. We surveyed 226 hospital staff as a case group and 222 office staff as a control group. All the subjects were asked to fill in a standard respiratory questionnaire. Pulmonary function parameters were simultaneously measured via a spirometry test. Environmental measurements of bio-aerosols, particulate matter, and volatile organic compounds in the hospital and offices were conducted. T-tests, chi-square tests, and multivariable logistic regressions were used to analyze the data. The concentration of selected air pollutants measured in the hospital wards was more than those in the administrative wards. Parameters of pulmonary functions were not statistically significant (p > 0.05) between the two groups. However, respiratory symptoms such as coughs, phlegm, phlegmatic coughs, and wheezing were more prevalent among the hospital staff. Laboratory staff members were more at risk of respiratory symptoms compared to other occupational groups in the hospital. The prevalence of sputum among nurses was significant, and the odds ratio for the presence of phlegm among nurses was 4.61 times greater than office staff (p = 0.002). The accumulation of indoor pollutants in the hospital environment revealed the failure of hospital ventilation systems. Hence, the design and implementation of an improved ventilation system in the studied hospital is recommended.
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Affiliation(s)
- Rahmat Veysi
- Department of Occupational Health Engineering, School of Public Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Behzad Heibati
- Air Pollution Research Center, Faculty of Health, Iran University of Medical Sciences, Tehran, Iran
| | - Mehdi Jahangiri
- Department of Occupational Health Engineering, School of Public Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Prashant Kumar
- Global Centre for Clean Air Research (GCARE), Department of Civil and Environmental Engineering, Faculty of Engineering and Physical Sciences, University of Surrey, Guildford, GU2 7XH, UK
| | - Mohd Talib Latif
- School of Environmental and Natural Resource Sciences, Universiti Kebangsaan Malaysia, 43600, Bangi, Selangor, Malaysia
| | - Ali Karimi
- Department of Occupational Health Engineering, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
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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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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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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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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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Kurth L, Virji MA, Storey E, Framberg S, Kallio C, Fink J, Laney AS. Current asthma and asthma-like symptoms among workers at a Veterans Administration Medical Center. Int J Hyg Environ Health 2017; 220:1325-1332. [PMID: 28923472 DOI: 10.1016/j.ijheh.2017.09.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 08/31/2017] [Accepted: 09/01/2017] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Healthcare workers are at increased risk for respiratory disorders. The purpose of our respiratory health survey was to estimate the prevalence of current asthma and asthma-like symptoms and their association with workplace exposures and tasks among healthcare workers at a Veterans Administration (VA) Medical Center. MATERIAL AND METHODS Information on respiratory health and work characteristics, including tasks performed, products used, and exposures, were collected by questionnaire from a convenience sample of workers employed at the VA Medical Center during 2012-2014. Associations of asthma and asthma-like symptoms with cleaning and disinfecting tasks and products as well as exposure to dampness and molds, and construction dust were evaluated using log-binomial regression. RESULTS The prevalence of current asthma was 17.6% and almost half of all workers reported asthma-like symptoms. We observed elevated prevalence of current asthma among the VA healthcare workers compared to the U.S. general and working adult populations. Asthma and asthma-like symptoms were significantly associated with mold, dampness, and construction material exposures; cleaning and disinfecting products; and cleaning or disinfecting tasks. CONCLUSIONS Workplace exposures and tasks associated with current asthma and asthma-like symptoms were identified but further research is needed to investigate the temporal association between workplace exposures and current asthma and asthma-like symptoms.
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Affiliation(s)
- Laura Kurth
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, WV, USA.
| | - Mohammed Abbas Virji
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, WV, USA
| | - Eileen Storey
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, WV, USA
| | - Susan Framberg
- Clement J. Zablocki VA Medical Center, Milwaukee, WI, USA
| | - Christa Kallio
- Clement J. Zablocki VA Medical Center, Milwaukee, WI, USA
| | - Jordan Fink
- Clement J. Zablocki VA Medical Center, Milwaukee, WI, USA
| | - Anthony Scott Laney
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, WV, USA
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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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Weinmann T, Gerlich J, Heinrich S, Nowak D, Mutius EV, Vogelberg C, Genuneit J, Lanzinger S, Al-Khadra S, Lohse T, Motoc I, Walter V, Radon K. Association of household cleaning agents and disinfectants with asthma in young German adults. Occup Environ Med 2017; 74:684-690. [PMID: 28483971 DOI: 10.1136/oemed-2016-104086] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 03/28/2017] [Accepted: 04/13/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We scrutinised the association of private use of household sprays and disinfectants with asthma incidence in young adults in the transition from school to working life. METHODS Between 2007 and 2009,2051 young adults aged 19-24 years living in two major German cities took part in the Study on Occupational Allergy Risks II. Self-reported exposure to household sprays and disinfectants was characterised according to a composite score for frequency of use as no use (score=0), low use (score between 1 and the median), medium use (score between the median and the 90th percentile) and high use (score above the 90th percentile). Two outcome variables (current asthma and current wheezing) with four mutually exclusive categories (never, incident, persistent and remittent) were used for the risk analyses. Multinomial logistic regression models examined the association between the frequency of using household sprays and disinfectants with asthma and wheezing adjusting for potential confounders. RESULTS Compared with no use, high use of disinfectants was associated with a more than twofold increased odds of incident asthma (OR 2.79, 95% CI 1.14 to 6.83). In addition, low/medium use of disinfectants was associated with remittent asthma (OR 2.39, 95% CI 1.29 to 4.47). The evidence for an association between high usage of household sprays and asthma incidence was weak (OR 2.79, 95% CI 0.84 to 9.20). CONCLUSION Our results support the hypothesis of an association between the use of cleaning products and elevated risks for asthma and wheezing in young adults at the start of working life.
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Affiliation(s)
- Tobias Weinmann
- Occupational and Environmental Epidemiology & NetTeaching Unit, Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, University Hospital of Munich (LMU), Munich, Germany
| | - Jessica Gerlich
- Occupational and Environmental Epidemiology & NetTeaching Unit, Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, University Hospital of Munich (LMU), Munich, Germany
| | - Sabine Heinrich
- Occupational and Environmental Epidemiology & NetTeaching Unit, Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, University Hospital of Munich (LMU), Munich, Germany
| | - Dennis Nowak
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, University Hospital of Munich (LMU), Munich, Germany
| | - Erika von Mutius
- Dr. v. Haunersches Kinderspital, University Hospital of Munich (LMU), Munich, Germany
| | - Christian Vogelberg
- Paediatric Department, University Hospital Carl Gustav Carus Dresden, TU Dresden, Dresden, Germany
| | - Jon Genuneit
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Stefanie Lanzinger
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | | | - Tina Lohse
- Epidemiology, Biostatistics and Prevention Institute, Chronic Disease Epidemiology, University of Zurich, Zurich, Switzerland
| | - Irina Motoc
- Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - Viola Walter
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Katja Radon
- Occupational and Environmental Epidemiology & NetTeaching Unit, Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, University Hospital of Munich (LMU), Munich, Germany
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Abrahamsen R, Fell AKM, Svendsen MV, Andersson E, Torén K, Henneberger PK, Kongerud J. Association of respiratory symptoms and asthma with occupational exposures: findings from a population-based cross-sectional survey in Telemark, Norway. BMJ Open 2017; 7:e014018. [PMID: 28336744 PMCID: PMC5372104 DOI: 10.1136/bmjopen-2016-014018] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVES The aim of this study was to estimate the prevalence of respiratory symptoms and physician-diagnosed asthma and assess the impact of current occupational exposure. DESIGN Cross-sectional analyses of the prevalence of self-reported respiratory health and association with current occupational exposure in a random sample of the general population in Telemark County, Norway. SETTINGS In 2013, a self-administered questionnaire was mailed to a random sample of the general population, aged 16-50, in Telemark, Norway. The overall response rate was 33%, comprising 16 099 responders. OUTCOME MEASURES The prevalence for respiratory symptoms and asthma, and OR of respiratory symptoms and asthma for occupational groups and exposures were calculated. Occupational exposures were assessed using self-reported exposure and an asthma-specific job-exposure matrix (JEM). RESULTS The prevalence of physician-diagnosed asthma was 11.5%. For the occupational groups, the category with agriculture/fishery workers and craft/related trade workers was associated with wheezing and asthma attack in the past 12 months, showing OR 1.3 (1.1 to 1.6) and 1.9 (1.2 to 2.8), respectively. The group including technicians and associated professionals was also associated with wheezing OR 1.2 (1.0 to 1.3) and asthma attack OR 1.4 (1.1 to 1.9). The JEM data show that exposure to flour was associated with wheezing OR 3.2 (1.4 to 7.3) and woken with dyspnoea OR 3.5 (1.3 to 9.5), whereas exposures to diisocyanates, welding/soldering fumes and exposure to vehicle/motor exhaust were associated with dyspnoea OR 2.9 (1.5 to 5.7), 3.2 (1.6 to 6.4) and 1.4 (1.0 to 1.8), respectively. CONCLUSIONS The observed prevalence of physician-diagnosed asthma was 11.5%. The 'manual' occupations were associated with respiratory symptoms. Occupational exposure to flour, diisocyanates, welding/soldering fumes and vehicle/motor exhaust was associated with respiratory symptoms in the past 12 months and use of asthma medication. However, prospective data are needed to confirm the observed associations.
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Affiliation(s)
- R Abrahamsen
- Department of Occupational and Environmental Medicine, Telemark Hospital, Skien, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - A K M Fell
- Department of Occupational and Environmental Medicine, Telemark Hospital, Skien, Norway
| | - M V Svendsen
- Department of Occupational and Environmental Medicine, Telemark Hospital, Skien, Norway
| | - E Andersson
- Department of Occupational and Environmental Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - K Torén
- Department of Occupational and Environmental Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - P K Henneberger
- Respiratory Health Division, National Institute for Occupational Safety and Health (NIOSH), Morgantown, West Virginia, USA
| | - J Kongerud
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Respiratory Medicine, Oslo University Hospital, Oslo, Norway
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Watanabe M, Kurai J, Sano H, Torai S, Yanase H, Funakoshi T, Fukada A, Hayakawa S, Kitano H, Shimizu E. Prevalence of allergic rhinitis based on the SACRA questionnaire among Japanese nursing professionals with asthma. THE JOURNAL OF MEDICAL INVESTIGATION 2017; 63:108-13. [PMID: 27040063 DOI: 10.2152/jmi.63.108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Although adult asthma is attributable to occupational factors and asthma and rhinitis are related, relatively few studies have investigated the prevalence of occupational rhinitis based on occupation, and knowledge of occupational rhinitis in Japan is currently limited. The objective of this cross-sectional study was to estimate the prevalence of allergic rhinitis among Japanese nursing professionals with asthma. A postal survey was conducted from October to December 2013 using translated versions of the European Community Respiratory Health Survey for the prevalence of asthma and State of the Impact of Allergic Rhinitis on Asthma Control questionnaire for the prevalence of rhinitis. Of 4,634 Japanese nursing professionals, 497 subjects had asthma, and 270 of these 497 subjects had allergic rhinitis (54.3%; 95% confidence interval [CI], 49.7-58.7). Latex allergy was significantly associated with allergic rhinitis (odds ratio, 1.77; 95% CI, 1.21-2.60). There was no relationship between employment period and prevalent allergic rhinitis. The results of this study provide fundamental information regarding occupational health among Japanese nursing professionals, including the prevalence of allergic rhinitis among Japanese nursing professionals with asthma and latex allergy as a potential risk factor for prevalent allergic rhinitis.
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Affiliation(s)
- Masanari Watanabe
- Department of Respiratory Medicine and Rheumatology, Tottori University Faculty of Medicine
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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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42
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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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43
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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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44
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Kurai J, Watanabe M, Sano H, Torai S, Yanase H, Funakoshi T, Fukada A, Hayakawa S, Shimizu E, Kitano H. Asthma and Wheeze Prevalence among Nursing Professionals in Western Japan: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2015; 12:15459-69. [PMID: 26690187 PMCID: PMC4690933 DOI: 10.3390/ijerph121214997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 11/21/2015] [Accepted: 12/03/2015] [Indexed: 11/16/2022]
Abstract
Although adult asthma is attributable to occupational factors, few reports are available on asthma prevalence among health care workers in Japan. The objective of this study was to estimate the prevalence of asthma and wheeze among Japanese nursing professionals. A cross-sectional study was conducted by postal survey using a translated version of the European Community Respiratory Health Survey questionnaire from April to June 2013. The analysis included 4634 nursing professionals (257 men and 4377 women) and the overall response rate was 84.8%. The prevalence of current asthma and wheeze were 10.7% (95% confidence interval (CI), 9.9%-11.7%) and 15.6% (95% CI, 14.5%-16.6%), respectively. More than one year of work experience as a nursing professional and more than one year of experience with bed-making tasks were associated with odds ratios (ORs) of 1.95 (95% CI, 1.12-3.39) and 1.64 (95% CI, 1.15-2.23) for wheeze, respectively. Current smoking was significantly associated with the presence of wheeze, with ORs of 2.27 for men (95% CI, 1.11-4.64) and 2.01 for women (95% CI, 1.54-2.64). Among female nurses, latex allergy was associated with wheeze (OR, 1.87; 95% CI, 1.56-2.23), as was body mass index ≥30 (OR, 2.76; 95% CI, 1.65-4.62). This study has provided the prevalence of asthma and wheeze among Japanese nursing professionals. Employment period, bed-making tasks, latex allergy, obesity, and smoking may be risk factors for prevalent wheeze among nursing professionals.
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Affiliation(s)
- Jun Kurai
- Department of Respiratory Medicine and Rheumatology, Faculty of Medicine, Tottori University, 36-1 Nishi-cho, Yonago 683-8504, Japan.
| | - Masanari Watanabe
- Department of Respiratory Medicine and Rheumatology, Faculty of Medicine, Tottori University, 36-1 Nishi-cho, Yonago 683-8504, Japan.
| | - Hiroyuki Sano
- Department of Respiratory Medicine and Allergology, Faculty of Medicine, Kinki University, 377-2 Ohnohigashi, Osakasayama 589-0014, Japan.
| | - Saeko Torai
- Tottori Nursing Association, 318-1 Gotsu, Tottori 680-0901, Japan.
| | - Hirokazu Yanase
- Division of Nursing, Tottori University Hospital, 36-1 Nishi-cho, Yonago 683-8504, Japan.
| | - Tomoaki Funakoshi
- Division of Nursing, Tottori University Hospital, 36-1 Nishi-cho, Yonago 683-8504, Japan.
| | - Atsuko Fukada
- Division of Nursing, Tottori University Hospital, 36-1 Nishi-cho, Yonago 683-8504, Japan.
| | - Sachiko Hayakawa
- Department of Public Relations, Tottori University Hospital, 36-1 Nishi-cho, Yonago 683-8504, Japan.
| | - Eiji Shimizu
- Department of Respiratory Medicine and Rheumatology, Faculty of Medicine, Tottori University, 36-1 Nishi-cho, Yonago 683-8504, Japan.
| | - Hiroya Kitano
- The Board of Directors, Tottori University, 4-101 Koyamachou-Minami, Tottori 68-8550, Japan.
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Quinn MM, Henneberger PK, Braun B, Delclos GL, Fagan K, Huang V, Knaack JL, Kusek L, Lee SJ, Le Moual N, Maher KA, McCrone SH, Mitchell AH, Pechter E, Rosenman K, Sehulster L, Stephens AC, Wilburn S, Zock JP. Cleaning and disinfecting environmental surfaces in health care: Toward an integrated framework for infection and occupational illness prevention. Am J Infect Control 2015; 43:424-34. [PMID: 25792102 DOI: 10.1016/j.ajic.2015.01.029] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 01/25/2015] [Accepted: 01/27/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The Cleaning and Disinfecting in Healthcare Working Group of the National Institute for Occupational Safety and Health, National Occupational Research Agenda, is a collaboration of infection prevention and occupational health researchers and practitioners with the objective of providing a more integrated approach to effective environmental surface cleaning and disinfection (C&D) while protecting the respiratory health of health care personnel. METHODS The Working Group, comprised of >40 members from 4 countries, reviewed current knowledge and identified knowledge gaps and future needs for research and practice. RESULTS An integrated framework was developed to guide more comprehensive efforts to minimize harmful C&D exposures without reducing the effectiveness of infection prevention. Gaps in basic knowledge and practice that are barriers to an integrated approach were grouped in 2 broad areas related to the need for improved understanding of the (1) effectiveness of environmental surface C&D to reduce the incidence of infectious diseases and colonization in health care workers and patients and (2) adverse health impacts of C&D on health care workers and patients. Specific needs identified within each area relate to basic knowledge, improved selection and use of products and practices, effective hazard communication and training, and safer alternatives. CONCLUSION A more integrated approach can support multidisciplinary teams with the capacity to maximize effective and safe C&D in health care.
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46
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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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47
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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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48
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Gonzalez M, Jégu J, Kopferschmitt MC, Donnay C, Hedelin G, Matzinger F, Velten M, Guilloux L, Cantineau A, de Blay F. Asthma among workers in healthcare settings: role of disinfection with quaternary ammonium compounds. Clin Exp Allergy 2014; 44:393-406. [PMID: 24128009 DOI: 10.1111/cea.12215] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 09/15/2013] [Accepted: 09/23/2013] [Indexed: 12/26/2022]
Abstract
INTRODUCTION An increased incidence of asthma has been reported among healthcare workers. The role of quaternary ammonium compounds (QACs), commonly used in cleaning/disinfection products, has not been clearly defined. The aim of this study was to analyse associations between asthma and occupational exposure to disinfectants, especially QACs. METHODS The study was performed on a stratified random sample of the various healthcare departments of 7 healthcare settings. The study included: questionnaire, physical examination and specific IgE assays. Occupational exposure assessment was performed by means of a work questionnaire, workplace studies and a review of products ingredients. Data were analysed by logistic regression. RESULTS Response rate was 77%; 543 workers (89% female) participated; 37.1% were registered nurses (RNs), 16.4% auxiliary nurses (ANs), 17.3% cleaners; 32.8% were atopic. 335 participants were exposed to QACs. Nursing professionals reported a significantly higher risk of reported physician-diagnosed asthma and, for RNs, of nasal symptoms at work than administrative staff working in healthcare sector. This risk was particularly marked during disinfection tasks and when exposure to QACs. Exposure to QACs increased significantly the risk of reported physician-diagnosed asthma and nasal symptoms at work (adjusted OR = 7.5 and 3.2, respectively). No significant association was found with other exposures such as latex glove use, chlorinated products/bleach or glutaraldehyde. CONCLUSION RNs and ANs presented a higher risk of reported asthma than administrative staff. The highest risk was associated with tasks involving dilution of disinfection products by manual mixing, suggesting possible exposure to repeated peaks of concentrated products known to be strong respiratory irritants. Workplace interventions should be conducted to more clearly determine QAC exposure and improve disinfection procedures.
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Affiliation(s)
- M Gonzalez
- Occupational Diseases Department, University Hospitals, Strasbourg, France; Department of Occupational Medicine, Faculty of Medicine, University of Strasbourg, Strasbourg, France
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49
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Occupational allergy: respiratory hazards in healthcare workers. Curr Opin Allergy Clin Immunol 2014; 14:113-8. [PMID: 24451912 DOI: 10.1097/aci.0000000000000039] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW Allergens are one group of respiratory hazards in the workplace of healthcare workers (HCWs). The purpose of this review is to summarize the recent advances in occupational allergy as well as potential hazardous agents in HCWs. RECENT FINDINGS The review covers new developments on the epidemiology, diagnosis and management of occupational allergy in HCWs. This article also provides updated information on the prevalence of work-related respiratory symptoms, as well as on respiratory hazards among healthcare providers. SUMMARY It is established that HCWs are at risk of asthma symptoms. The growing use of cleaning products is one of the causes of occupational airway disease in that group. Among healthcare professionals, the prevalence of asthma varies depending on worksite. Recent findings indicate a need for education among HCWs concerning occupational risks. A lack of knowledge of product components as well as about exposure to cleaning/disinfecting agents has been demonstrated. Further studies are necessary to determine the relative role of individual agents versus complex workplace exposures in the development of work-related asthma in HCWs.
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Vandenplas O, Wiszniewska M, Raulf M, de Blay F, Gerth van Wijk R, Moscato G, Nemery B, Pala G, Quirce S, Sastre J, Schlünssen V, Sigsgaard T, Siracusa A, Tarlo SM, van Kampen V, Zock JP, Walusiak-Skorupa J. EAACI position paper: irritant-induced asthma. Allergy 2014; 69:1141-53. [PMID: 24854136 DOI: 10.1111/all.12448] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2014] [Indexed: 01/18/2023]
Abstract
The term irritant-induced (occupational) asthma (IIA) has been used to denote various clinical forms of asthma related to irritant exposure at work. The causal relationship between irritant exposure(s) and the development of asthma can be substantiated by the temporal association between the onset of asthma symptoms and a single or multiple high-level exposure(s) to irritants, whereas this relationship can only be inferred from epidemiological data for workers chronically exposed to moderate levels of irritants. Accordingly, the following clinical phenotypes should be distinguished within the wide spectrum of irritant-related asthma: (i) definite IIA, that is acute-onset IIA characterized by the rapid onset of asthma within a few hours after a single exposure to very high levels of irritant substances; (ii) probable IIA, that is asthma that develops in workers with multiple symptomatic high-level exposures to irritants; and (iii) possible IIA, that is asthma occurring with a delayed-onset after chronic exposure to moderate levels of irritants. This document prepared by a panel of experts summarizes our current knowledge on the diagnostic approach, epidemiology, pathophysiology, and management of the various phenotypes of IIA.
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Affiliation(s)
- O. Vandenplas
- Department of Chest Medicine; Centre Hospitalier Universitaire de Mont-Godinne; Université Catholique de Louvain; Yvoir Belgium
| | - M. Wiszniewska
- Department of Occupational Diseases and Clinical Toxicology; Nofer Institute of Occupational Medicine; Lodz Poland
| | - M. Raulf
- IPA Institute for Prevention and Occupational Medicine of the German Social Accident Insurance; Institute of the Ruhr-Universität Bochum; Bochum Germany
| | - F. de Blay
- Division of Asthma and Allergy; Department of Chest Diseases; University Hospital; Fédération de Médecine Translationnelle de Strasbourg; Strasbourg University; Strasbourg France
| | - R. Gerth van Wijk
- Section of Allergology; Department of Internal Medicine; Erasmus MC; Rotterdam The Netherlands
| | - G. Moscato
- Department of Public Health; Experimental and Forensic Medicine of the University of Pavia; Pavia Italy
| | - B. Nemery
- Department of Public Health and Primary Care; KU Leuven; Leuven Belgium
| | - G. Pala
- Occupational Physician's Division; Local Health Authority of Sassari; Sassari Italy
| | - S. Quirce
- Department of Allergy; Hospital La Paz Institute for Health Research (IdiPAZ); CIBER de Enfermedades Respiratorias (CIBERES); Madrid Spain
| | - J. Sastre
- Department of Allergy; Fundación Jiménez Díaz; CIBER de Enfermedades Respiratorias (CIBERES); Madrid Spain
| | - V. Schlünssen
- Section of Environment, Occupation and Health; Department of Public Health; University of Aarhus; Aarhus Denmark
| | - T. Sigsgaard
- Section of Environment, Occupation and Health; Department of Public Health; University of Aarhus; Aarhus Denmark
| | - A. Siracusa
- Formerly Department of Clinical and Experimental Medicine; University of Perugia; Perugia Italy
| | - S. M. Tarlo
- Department of Medicine and Dalla Lana School of Public Health; University of Toronto; Toronto ON Canada
- Respiratory Division; Toronto Western Hospital; Toronto ON Canada
- Gage Occupational and Environmental Health Unit; St Michael's Hospital; Toronto ON Canada
| | - V. van Kampen
- IPA Institute for Prevention and Occupational Medicine of the German Social Accident Insurance; Institute of the Ruhr-Universität Bochum; Bochum Germany
| | - J.-P. Zock
- Centre for Research in Environmental Epidemiology (CREAL); Barcelona Spain
- Universitat Pompeu Fabra (UPF); Barcelona Spain
- Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública (CIBERESP); Madrid Spain
- Netherlands Institute of Health Services Research (NIVEL); Utrecht the Netherlands
| | - J. Walusiak-Skorupa
- Department of Occupational Diseases and Clinical Toxicology; Nofer Institute of Occupational Medicine; Lodz Poland
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