Early-life exposure to humidifier disinfectant determines the prognosis of lung function in children

Polyhexamethylene guanidine aerosol causes irreversible changes in blood proteins that associated with the severity of lung injury

Polyhexamethylene guanidine (PHMG) is a positively charged polymer used as a disinfectant that kills microbes but can cause pulmonary fibrosis if inhaled. After the long-term risks were confirmed in South Korea, it became crucial to measure toxicity through diverse surrogate biomarkers, not only proteins, especially after these hazardous chemicals had cleared from the body. These biomarkers, identified by their biological functions rather than simple numerical calculations, effectively explained the imbalance of pulmonary surfactant caused by fibrosis from PHMG exposure. These long-term studies on children exposed to PHMG has shown that blood protein indicators, primarily related to apolipoproteins and extracellular matrix, can distinguish the degree of exposure to humidifier disinfectants (HDs). We defined the extreme gradient boosting models and computed reflection scores based on just ten selected proteins, which were also verified in adult women exposed to HD. The reflection scores successfully discriminated between the HD-exposed and unexposed groups in both children and adult females (AUROC: 0.957 and 0.974, respectively) and had a strong negative correlation with lung function indicators. Even after an average of more than 10 years, blood is still considered a meaningful specimen for assessing the impact of environmental exposure to toxic substances, with proteins providing in identifying the pathological severity of such conditions.

Health Effects Associated With Humidifier Disinfectant Use: A Systematic Review for Exploration

BACKGROUND

It has been 10 years since the outbreak of lung disease caused by humidifier disinfectants in Korea, but the health effects have not yet been summarized. Therefore, this study aims to systematically examine the health effects of humidifier disinfectants that have been discovered so far.

METHODS

All literature with humidifier disinfectants and their representative components as the main words were collected based on the web, including PubMed, Research Information Sharing Service, and government publication reports. A total of 902 studies were searched, of which 196 were selected. They were divided into four groups: published human studies (group 1), published animal and cytotoxicology studies (group 2), technical reports (group 3), and gray literature (group 4).

RESULTS

Out of the 196 studies, 97 (49.5%) were published in peer-reviewed journals as original research. Group 1 consisted of 49 articles (50.5%), while group 2 consisted of 48 articles (49.5%). Overall, respiratory diseases such as humidifier disinfectant associated lung injury, interstitial lung disease, and asthma have a clear correlation, but other effects such as liver, heart, thymus, thyroid, fetal growth, metabolic abnormalities, and eyes are observed in toxicological experimental studies, but have not yet been identified in epidemiologic studies.

CONCLUSION

The current level of evidence does not completely rule out the effects of humidifier disinfectants on extrapulmonary disease. Based on the toxicological evidence so far, it is required to monitor the population of humidifier disinfectant exposure continuously to see if similar damage occurs.

Functional and dynamic mitochondrial damage by chloromethylisothiazolinone/methylisothiazolinone (CMIT/MIT) mixture in brain endothelial cell lines and rat cerebrovascular endothelium

The mixture of 5-chloro-2-methyl-4-isothiazolin-3-one (CMIT, chloromethylisothiazolinone) and 2-methyl-4-isothiazolin-3-one (MIT, methylisothiazolinone) is a commonly used biocide in consumer products. Despite the health issues related to its usage in cosmetics and humidifier disinfectants (HD), understanding its adverse outcome is still limited. Using in vitro cell lines and ex vivo rat models, we examined the effects of CMIT/MIT on the cellular redox homeostasis and energy metabolism in the brain microvascular endothelium, a highly restrictive interface between the bloodstream and brain. In murine bEND.3 and human hCMEC/D3, CMIT/MIT significantly amplified the mitochondrial-derived oxidative stress causing disruption of the mitochondrial membrane potential and oxidative phosphorylation at a sub-lethal concentration (1 μg/mL) or treatment duration (1 h). In addition, CMIT/MIT significantly increased a dynamic imbalance between mitochondrial fission and fusion, and endogenous pathological stressors significantly potentiated the CMIT/MIT-induced endothelial dysfunction. Notably, in the brain endothelium isolated from intravenously CMIT/MIT-administered rats, we observed significant mitochondrial damage and decreased tight junction protein. Taken together, we report that CMIT/MIT significantly impaired mitochondrial function and dynamics resulting in endothelial barrier dysfunction, giving an insight into the role of mitochondrial damage in CMIT/MIT-associated systemic health effects.

3D Printed SERS-Active Thin-Film Substrates Used to Quantify Levels of the Genotoxic Isothiazolinone

Several reports present methods to fabricate thin-film substrates capable of surface-enhanced Raman scattering (SERS). Substrates synthesized by displacing silver onto copper using facile synthesis methods such as galvanic displacement can generate high levels of SERS enhancement rivaling commercially available substrates manufactured by lithographic methods. Here, we describe the optimization of a novel set of SERS-active thin-film substrates synthesized via the electroless displacement of Ag onto the surface of three-dimensional (3D) printed disks composed of the copper/polymer (PLA) composite filament. The effect of AgNO₃ concentration on the deposition, morphology, and overall SERS activity of the substrates has been carefully studied. Two commonly used Raman reporters, 4-mercaptobenzoic acid (MBA) and malachite green isothiocyanate (MGITC), were used to measure the SERS output of the substrates. Good SERS signal reproducibility (RSD ∼16.8%) was measured across the surface of replicate substrates and high-sensitivity detection of MBA was achieved (10^-12 M). To test the real-world application of our substrates, we opted to detect 5-chloro-2-methyl-4-isothiazolin-3-one (CMIT), which is a genotoxic, biocide common in many household products, known to leach into water supplies. Our newly developed SERS-active substrates could detect CMIT down to 10 ppm when spiked in simulated lake water samples, which is well within current agency standards.

Assessment of agonistic and antagonistic properties of humidifier disinfectants to the estrogenic and androgenic receptors by transactivation assay

Before being recalled and banned from the Korean market, humidifier disinfectants (HDs) were added to the humidifier water tank to prevent microbial growth. The known HDs active ingredients included the are oligo(2-(2-ethoxy)ethoxyethyl guanidine (PGH), polyhexamethylene guanidine (PHMG), a mixture of methylisothiazolinone (MIT) and chloromethylisothiazolinone (CMIT), didecyldimethyl ammonium chloride (DDAC), Sodium dichloroisocyanurate (NaDCC), and alkyldimethylbenzyl ammonium chloride (BAC). Previous epidemiological studies have suggested that PHMG induces fatal lung disease in pregnant, post-partum women, and young children. In an animal study, a mixture of DDAC and BAC exhibited decreased fertility and fecundity; increased time to first litter, longer pregnancy intervals, fewer pups per litter, and fewer pregnancies. In this study, endocrine-disrupting effects of HDs were investigated using estrogen receptor (ER) and androgen receptor (AR) transactivation assay based on OECD Test guidelines. Unexpectedly, unlike the previously reported reproductive toxicity data, in the present study, HDs did not show ER and AR transcriptional activation agonist and/or antagonist effects. However, it is difficult to conclude that HDs has no endocrine disruption effects, and further research on the effects of HDs mixtures, and in vivo tests including Uterotrophic bioassay and Hershberger bioassay would be necessary.

Prenatal Exposure to Heavy Metals Affects Gestational Age by Altering DNA Methylation Patterns

Environmental exposure is known to have toxic effects. Maternal environmental exposure not only affects mothers but also their fetuses in utero, which may interrupt their early development. Preterm birth, one of the outcomes of prenatal exposure, is a significant factor in lifelong health risks. To understand the effects of prenatal exposome on preterm birth, we studied the association between maternal and prenatal heavy metal exposure and gestational age, using resources from the MOthers' and Children's Environmental Health (MOCEH) study in South Korea. Additionally, a methylation assay was performed to analyze epigenetic mediation using genomic DNA derived from the cord blood of 384 participants in the MOCEH study. The results suggest that maternal cadmium exposure is associated with a decrease in gestational age through an alteration in DNA methylation at a specific CpG site, cg21010642. The CpG site was annotated to a gene involved in early embryonic development. Therefore, irregular methylation patterns at this site may contribute to premature birth by mediating irregular biological mechanisms.

Fibrosis as a result of polyhexamethylene guanide exposure in cultured Statens Seruminstitut Rabbit Cornea (SIRC) cells

Previous research studies on the toxicity of polyhexamethylene guanidine (PHMG) as a humidifier disinfectant majorly focused on lung fibrosis. Considering that disinfectants in humidifiers are released in aerosol form, the eyes are directly exposed and highly vulnerable to the detrimental effects of the PHMG. Therefore, in the present study we investigated the adverse effects of PHMG on the eyes; considering fibrosis as a manifestation of PHMG toxicity in the eye, we evaluated fibrosis-related biomarkers in cultured Statens Seruminstitut Rabbit Cornea (SIRC) cells. Cell viability was measured using 3-(4,5-dimethylthiazol-2-yl)-2, 5-diphenyltetrazolium bromide (MTT) assay, fibrosis-related biomarkers were evaluated through polymerase chain reaction (PCR) and immunoblotting, and oxidative stress was evaluated using 2',7'-dichlorodihydrofluorescein diacetate (H2DCFDA). Polyhexamethylene guanidine showed cytotoxicity in a time and concentration-dependent manner. Fibrosis related biomarkers including transforming growth factor-β (TGF-β), α-smooth muscle actin (α-SMA), matrix metalloproteinase (MMP), tissue inhibitor of metalloproteinase (TIMP) and hemeoxygenase-1 (HO-1) increased in both gene and protein levels. Oxidative stress also increased in the PHMG-treated cultured cells. The findings of the present study suggest that PHMG could cause toxicity in the eye as manifested by fibrosis.

Different Characteristics of Childhood Asthma Related to Polyhexamethylene Guanidine Hydrochloride (PHMG) Exposure

RATIONALE

Exposure to humidifier disinfectants (HDs) can increase the risk of asthma but the characteristics of HD-related asthma are currently unclear. Polyhexamethylene guanidine hydrochloride (PHMG)-containing HD was the most commonly used and the most frequently associated with HD-associated lung injury.

OBJECTIVES

To investigate the characteristics of PHMG-induced asthma.

METHODS

This general population-based birth cohort study utilized data from the Panel Study of Korean Children from 2008 (n = 846). Spirometry, bronchial provocation tests, detailed history recording, and physical examinations were performed on seven-year-old patients (n=362). Exploratory analysis of plasma proteomics was performed.

RESULTS

Compared with healthy control, FEV1 was the lowest in PHMG-exposed asthma group. (z score = -0.806; 95% CI, -1.492 to -0.119) The positive rate of bronchial hyperresponsiveness was lower in children with PHMG-exposed asthma compared to children with asthma without HD exposure (13.3% vs. 47.4%). Long-term exposure to low-intensity PHMG before age three was associated with asthma symptoms. Periostin was higher in asthma without HD exposure compared to the healthy control. The inducible T cell costimulator ligand and hepatocyte growth factor activator were lower in PHMG-exposed asthma compared to asthma without exposure. Hepatocyte growth factor activator a positive correlation with FVC (z-score) in asthma with PHMG exposure (r=0.78, P<0.01).

CONCLUSIONS

The asthma associated with low intensity exposure to PHMG is characterized by lower lung function, lower positive rates of bronchial hyperresponsiveness, and varied distributions of plasma proteins. These findings suggest that asthma related to PHMG exposure may constitute a different mechanism of asthma pathophysiology.

The past, present, and future of humidifier disinfectant-associated interstitial lung diseases in children

Exposure to environmental factors can cause interstitial lung diseases (ILDs); however, such types of ILDs are rare. From 2007 to 2011, an ILD epidemic occurred in South Korea owing to inhalational exposure to toxic chemicals in humidifier disinfectants (HDs). HD-associated ILDs (HD-ILDs) are characterized by rapidly progressing respiratory failure with pulmonary fibrosis and a high mortality rate of 43.8%-58.0%. Although 18.1%-31.1% of the general population used HDs, only a small proportion of HD users were diagnosed with HD-ILDs. This finding suggests that investigation of the pathophysiologies underlying HD-ILDs is needed in addition to the identification of susceptibility to HD-ILDs. Further, there have been several concerns regarding the diverse health effects of exposure to toxic chemicals in HDs, including those that have not been identified, and long-term prognoses in terms of pulmonary function and residual pulmonary lesions observed on follow-up chest images. In this review, we summarize the clinical features, pathologic findings, and changes in radiologic findings over time in patients with HD-ILDs and the results of previous experimental research on the mechanisms underlying the effects of toxic chemicals in HDs. Studies are currently underway to identify the pathophysiologies of HD-ILDs and possible health effects of exposure to HDs along with the development of targeted therapeutic strategies. The experience of identification of HD-ILDs has encouraged stricter control of safe chemicals in everyday life.