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Gu X, Watson C, Agrawal U, Whitaker H, Elson WH, Anand S, Borrow R, Buckingham A, Button E, Curtis L, Dunn D, Elliot AJ, Ferreira F, Goudie R, Hoang U, Hoschler K, Jamie G, Kar D, Kele B, Leston M, Linley E, Macartney J, Marsden GL, Okusi C, Parvizi O, Quinot C, Sebastianpillai P, Sexton V, Smith G, Suli T, Thomas NPB, Thompson C, Todkill D, Wimalaratna R, Inada-Kim M, Andrews N, Tzortziou-Brown V, Byford R, Zambon M, Lopez-Bernal J, de Lusignan S. Postpandemic Sentinel Surveillance of Respiratory Diseases in the Context of the World Health Organization Mosaic Framework: Protocol for a Development and Evaluation Study Involving the English Primary Care Network 2023-2024. JMIR Public Health Surveill 2024; 10:e52047. [PMID: 38569175 PMCID: PMC11024753 DOI: 10.2196/52047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 01/02/2024] [Accepted: 01/17/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Prepandemic sentinel surveillance focused on improved management of winter pressures, with influenza-like illness (ILI) being the key clinical indicator. The World Health Organization (WHO) global standards for influenza surveillance include monitoring acute respiratory infection (ARI) and ILI. The WHO's mosaic framework recommends that the surveillance strategies of countries include the virological monitoring of respiratory viruses with pandemic potential such as influenza. The Oxford-Royal College of General Practitioner Research and Surveillance Centre (RSC) in collaboration with the UK Health Security Agency (UKHSA) has provided sentinel surveillance since 1967, including virology since 1993. OBJECTIVE We aim to describe the RSC's plans for sentinel surveillance in the 2023-2024 season and evaluate these plans against the WHO mosaic framework. METHODS Our approach, which includes patient and public involvement, contributes to surveillance objectives across all 3 domains of the mosaic framework. We will generate an ARI phenotype to enable reporting of this indicator in addition to ILI. These data will support UKHSA's sentinel surveillance, including vaccine effectiveness and burden of disease studies. The panel of virology tests analyzed in UKHSA's reference laboratory will remain unchanged, with additional plans for point-of-care testing, pneumococcus testing, and asymptomatic screening. Our sampling framework for serological surveillance will provide greater representativeness and more samples from younger people. We will create a biomedical resource that enables linkage between clinical data held in the RSC and virology data, including sequencing data, held by the UKHSA. We describe the governance framework for the RSC. RESULTS We are co-designing our communication about data sharing and sampling, contextualized by the mosaic framework, with national and general practice patient and public involvement groups. We present our ARI digital phenotype and the key data RSC network members are requested to include in computerized medical records. We will share data with the UKHSA to report vaccine effectiveness for COVID-19 and influenza, assess the disease burden of respiratory syncytial virus, and perform syndromic surveillance. Virological surveillance will include COVID-19, influenza, respiratory syncytial virus, and other common respiratory viruses. We plan to pilot point-of-care testing for group A streptococcus, urine tests for pneumococcus, and asymptomatic testing. We will integrate test requests and results with the laboratory-computerized medical record system. A biomedical resource will enable research linking clinical data to virology data. The legal basis for the RSC's pseudonymized data extract is The Health Service (Control of Patient Information) Regulations 2002, and all nonsurveillance uses require research ethics approval. CONCLUSIONS The RSC extended its surveillance activities to meet more but not all of the mosaic framework's objectives. We have introduced an ARI indicator. We seek to expand our surveillance scope and could do more around transmissibility and the benefits and risks of nonvaccine therapies.
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Affiliation(s)
- Xinchun Gu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Conall Watson
- Immunisation and Vaccine-Preventable Diseases Division, UK Health Security Agency, London, United Kingdom
| | - Utkarsh Agrawal
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Heather Whitaker
- Statistics, Modelling and Economics Department, UK Health Security Agency, London, United Kingdom
| | - William H Elson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Sneha Anand
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Ray Borrow
- Vaccine Evaluation Unit, UK Health Security Agency, Manchester, United Kingdom
| | | | - Elizabeth Button
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Lottie Curtis
- Royal College of General Practitioners, London, United Kingdom
| | - Dominic Dunn
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Alex J Elliot
- Real-time Syndromic Surveillance Team, UK Health Security Agency, Birmingham, United Kingdom
| | - Filipa Ferreira
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Rosalind Goudie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Uy Hoang
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Katja Hoschler
- Respiratory Virus Unit, UK Health Security Agency, London, United Kingdom
| | - Gavin Jamie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Debasish Kar
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Beatrix Kele
- Respiratory Virus Unit, UK Health Security Agency, London, United Kingdom
| | - Meredith Leston
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Ezra Linley
- Vaccine Evaluation Unit, UK Health Security Agency, Manchester, United Kingdom
| | - Jack Macartney
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Gemma L Marsden
- Royal College of General Practitioners, London, United Kingdom
| | - Cecilia Okusi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Omid Parvizi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- Respiratory Virus Unit, UK Health Security Agency, London, United Kingdom
| | - Catherine Quinot
- Immunisation and Vaccine-Preventable Diseases Division, UK Health Security Agency, London, United Kingdom
| | | | - Vanashree Sexton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Gillian Smith
- Real-time Syndromic Surveillance Team, UK Health Security Agency, Birmingham, United Kingdom
| | - Timea Suli
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | | | - Catherine Thompson
- Respiratory Virus Unit, UK Health Security Agency, London, United Kingdom
| | - Daniel Todkill
- Real-time Syndromic Surveillance Team, UK Health Security Agency, Birmingham, United Kingdom
| | - Rashmi Wimalaratna
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | | | - Nick Andrews
- Immunisation and Vaccine-Preventable Diseases Division, UK Health Security Agency, London, United Kingdom
| | | | - Rachel Byford
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Maria Zambon
- Virus Reference Department, UK Health Security Agency, London, United Kingdom
| | - Jamie Lopez-Bernal
- Immunisation and Vaccine-Preventable Diseases Division, UK Health Security Agency, London, United Kingdom
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Muhsen K, Waight PA, Kirsebom F, Andrews N, Letley L, Gower CM, Skarnes C, Quinot C, Lunt R, Bernal JL, Flasche S, Miller E. Association between COVID-19 Vaccination and SARS-CoV-2 Infection among Household Contacts of Infected Individuals: A Prospective Household Study in England. Vaccines (Basel) 2024; 12:113. [PMID: 38400097 PMCID: PMC10892628 DOI: 10.3390/vaccines12020113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/07/2024] [Accepted: 01/18/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND We investigated whether COVID-19 vaccination reduced SARS-CoV-2 infection risk among adult household contacts of COVID-19 index cases during the Alpha, Delta, and Omicron waves in England. METHODS Between February 2021 and February 2022, SARS-CoV-2 RT-PCR nasal swabs were collected from COVID-19-confirmed index cases aged ≥20 years and their household contacts at enrolment and three and seven days thereafter. Generalized Estimating Equations models were fitted with SARS-CoV-2 positivity as the outcome and household contacts' vaccination status as the main exposure while adjusting for confounders. RESULTS SARS-CoV-2 infection was confirmed in 238/472 household contacts (50.4%) aged ≥20 years. The adjusted relative risk (95% confidence interval) of infection in vaccinated versus unvaccinated household contacts was 0.50 (0.35-0.72) and 0.69 (0.53-0.90) for receipt of two doses 8-90 and >90 days ago, respectively, and 0.34 (0.23-0.50) for vaccination with three doses 8-151 days ago. Primary vaccination protected household contacts against infection during the Alpha and Delta waves, but only three doses protected during the Omicron wave. Vaccination with three doses in the index case independently reduced contacts' infection risk: 0.45 (0.23-0.89). CONCLUSIONS Vaccination of household contacts reduces their risk of infection under conditions of household exposure though, for Omicron, only after a booster dose.
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Affiliation(s)
- Khitam Muhsen
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty of Medicine, Tel Aviv University, Tel Aviv 6139001, Israel
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK; (S.F.); (E.M.)
| | - Pauline A. Waight
- UK Health Security Agency, 61 Colindale Avenue, London NW9 5EU, UK; (P.A.W.); (F.K.); (N.A.); (C.S.); (J.L.B.)
| | - Freja Kirsebom
- UK Health Security Agency, 61 Colindale Avenue, London NW9 5EU, UK; (P.A.W.); (F.K.); (N.A.); (C.S.); (J.L.B.)
| | - Nick Andrews
- UK Health Security Agency, 61 Colindale Avenue, London NW9 5EU, UK; (P.A.W.); (F.K.); (N.A.); (C.S.); (J.L.B.)
| | - Louise Letley
- UK Health Security Agency, 61 Colindale Avenue, London NW9 5EU, UK; (P.A.W.); (F.K.); (N.A.); (C.S.); (J.L.B.)
| | - Charlotte M. Gower
- UK Health Security Agency, 61 Colindale Avenue, London NW9 5EU, UK; (P.A.W.); (F.K.); (N.A.); (C.S.); (J.L.B.)
| | - Catriona Skarnes
- UK Health Security Agency, 61 Colindale Avenue, London NW9 5EU, UK; (P.A.W.); (F.K.); (N.A.); (C.S.); (J.L.B.)
| | - Catherine Quinot
- UK Health Security Agency, 61 Colindale Avenue, London NW9 5EU, UK; (P.A.W.); (F.K.); (N.A.); (C.S.); (J.L.B.)
| | - Rachel Lunt
- UK Health Security Agency, 61 Colindale Avenue, London NW9 5EU, UK; (P.A.W.); (F.K.); (N.A.); (C.S.); (J.L.B.)
| | - Jamie Lopez Bernal
- UK Health Security Agency, 61 Colindale Avenue, London NW9 5EU, UK; (P.A.W.); (F.K.); (N.A.); (C.S.); (J.L.B.)
- NIHR Health Protection Research Unit in Respiratory Infections, Imperial College London, London SW7 2AZ, UK
| | - Stefan Flasche
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK; (S.F.); (E.M.)
| | - Elizabeth Miller
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK; (S.F.); (E.M.)
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Lunt R, Quinot C, Kirsebom F, Andrews N, Skarnes C, Letley L, Haskins D, Angel C, Firminger S, Ratcliffe K, Rajan S, Sherridan A, Ijaz S, Zambon M, Brown K, Ramsay M, Bernal JL. The impact of vaccination and SARS-CoV-2 variants on the virological response to SARS-CoV-2 infections during the Alpha, Delta, and Omicron waves in England. J Infect 2024; 88:21-29. [PMID: 37926118 DOI: 10.1016/j.jinf.2023.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/23/2023] [Accepted: 10/25/2023] [Indexed: 11/07/2023]
Abstract
Vaccination status and the SARS-CoV-2 variant individuals are infected with are known to independently impact viral dynamics; however, little is known about the interaction of these two factors and how this impacts viral dynamics. Here we investigated how monovalent vaccination modified the time course and viral load of infections from different variants. Regression analyses were used to investigate the impact of vaccination on cycle threshold values and disease severity, and interval-censored survival analyses were used to investigate the impact of vaccination on duration of positivity. A range of covariates were adjusted for as potential confounders and investigated for their own effects in exploratory analyses. All analyses were done combining all variants and stratified by variant. For those infected with Alpha or Delta, vaccinated individuals were more likely to report mild disease than moderate/severe disease and had significantly shorter duration of positivity and lower viral loads compared to unvaccinated individuals. Vaccination had no impact on self-reported disease severity, viral load, or duration if positivity for those infected with Omicron. Overall, individuals who were immunosuppressed and clinically extremely vulnerable had longer duration of positivity and higher viral loads. This study adds to the evidence base on disease dynamics following COVID-19, demonstrating that vaccination mitigates severity of disease, the amount of detectable virus within infected individuals and reduces the time individuals are positive for. However, these effects have been significantly attenuated since the emergence of Omicron. Therefore, our findings strengthen the argument for using modified or multivalent vaccines that target emerging variants.
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Affiliation(s)
- Rachel Lunt
- UK Health Security Agency, London, United Kingdom.
| | | | | | - Nick Andrews
- UK Health Security Agency, London, United Kingdom; NIHR Health Protection Research Unit in Vaccines and Immunisation, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | | | | | | | | | | | | | - Samreen Ijaz
- UK Health Security Agency, London, United Kingdom
| | - Maria Zambon
- UK Health Security Agency, London, United Kingdom; NIHR Health Protection Research Unit in Respiratory Infections, Imperial College London, London, United Kingdom
| | - Kevin Brown
- UK Health Security Agency, London, United Kingdom
| | - Mary Ramsay
- UK Health Security Agency, London, United Kingdom; NIHR Health Protection Research Unit in Vaccines and Immunisation, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jamie Lopez Bernal
- UK Health Security Agency, London, United Kingdom; NIHR Health Protection Research Unit in Vaccines and Immunisation, London School of Hygiene and Tropical Medicine, London, United Kingdom; NIHR Health Protection Research Unit in Respiratory Infections, Imperial College London, London, United Kingdom
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Andrianjafimasy MV, Febrissy M, Zerimech F, Dananché B, Kromhout H, Matran R, Nadif M, Oberson-Geneste D, Quinot C, Schlünssen V, Siroux V, Zock JP, Le Moual N, Nadif R, Dumas O. Response to: Correspondence on “Association between occupational exposure to irritant agents and a distinct asthma endotype in adults” by Andrianjafimasy et al. Occup Environ Med 2022; 79:359-360. [DOI: 10.1136/oemed-2021-108117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/18/2021] [Indexed: 11/03/2022]
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5
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Andrianjafimasy MV, Febrissy M, Zerimech F, Dananché B, Kromhout H, Matran R, Nadif M, Oberson-Geneste D, Quinot C, Schlünssen V, Siroux V, Zock JP, Le Moual N, Nadif R, Dumas O. Association between occupational exposure to irritant agents and a distinct asthma endotype in adults. Occup Environ Med 2021; 79:155-161. [PMID: 34413158 DOI: 10.1136/oemed-2020-107065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 07/22/2021] [Indexed: 11/04/2022]
Abstract
AIM The biological mechanisms of work-related asthma induced by irritants remain unclear. We investigated the associations between occupational exposure to irritants and respiratory endotypes previously identified among never asthmatics (NA) and current asthmatics (CA) integrating clinical characteristics and biomarkers related to oxidative stress and inflammation. METHODS We used cross-sectional data from 999 adults (mean 45 years old, 46% men) from the case-control and familial Epidemiological study on the Genetics and Environments of Asthma (EGEA) study. Five respiratory endotypes have been identified using a cluster-based approach: NA1 (n=463) asymptomatic, NA2 (n=169) with respiratory symptoms, CA1 (n=50) with active treated adult-onset asthma, poor lung function, high blood neutrophil counts and high fluorescent oxidation products level, CA2 (n=203) with mild middle-age asthma, rhinitis and low immunoglobulin E level, and CA3 (n=114) with inactive/mild untreated allergic childhood-onset asthma. Occupational exposure to irritants during the current or last held job was assessed by the updated occupational asthma-specific job-exposure matrix (levels of exposure: no/medium/high). Associations between irritants and each respiratory endotype (NA1 asymptomatic as reference) were studied using logistic regressions adjusted for age, sex and smoking status. RESULTS Prevalence of high occupational exposure to irritants was 7% in NA1, 6% in NA2, 16% in CA1, 7% in CA2 and 10% in CA3. High exposure to irritants was associated with CA1 (adjusted OR aOR, (95% CI) 2.7 (1.0 to 7.3)). Exposure to irritants was not significantly associated with other endotypes (aOR range: 0.8 to 1.5). CONCLUSION Occupational exposure to irritants was associated with a distinct respiratory endotype suggesting oxidative stress and neutrophilic inflammation as potential associated biological mechanisms.
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Affiliation(s)
- Miora Valérie Andrianjafimasy
- Université Paris-Saclay, UVSQ, Univ. Paris-Sud, Inserm, Équipe d'Épidémiologie respiratoire intégrative, CESP, 94807, Villejuif, Île-de-France, France
| | - Mickaël Febrissy
- LIPADE, Université Paris 5 Descartes, Paris, Île-de-France, France
| | - Farid Zerimech
- Univ. Lille, ULR 4483 - IMPECS, CHU Lille, F-59000 Lille, Lille, France.,Institut Pasteur de Lille, F-59000, Lille, France
| | | | - Hans Kromhout
- Utrecht University, Division of Environmental Epidemiology, Institute for Risk Assessment Sciences, Utrecht, Netherlands
| | - Régis Matran
- Univ. Lille, ULR 4483 - IMPECS, CHU Lille, F-59000 Lille, Lille, France.,Institut Pasteur de Lille, F-59000, Lille, France
| | - Mohamed Nadif
- LIPADE, Université Paris 5 Descartes, Paris, Île-de-France, France
| | | | - Catherine Quinot
- Université Paris-Saclay, UVSQ, Univ. Paris-Sud, Inserm, Équipe d'Épidémiologie respiratoire intégrative, CESP, 94807, Villejuif, Île-de-France, France
| | - Vivi Schlünssen
- Aarhus University, Department of Public Health, Environment, Occupation and Health, Danish Ramazzini Centre, Aarhus, Denmark.,National Research Centre for the Working Environment, Kobenhavn, Denmark
| | - Valérie Siroux
- Universite Grenoble Alpes, Inserm, CNRS, Team of environmental epidemiology applied to Reproduction and Respiratory health, IAB, Grenoble, France
| | - Jan-Paul Zock
- Institute for Global Health (ISGlobal) and Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Nicole Le Moual
- Université Paris-Saclay, UVSQ, Univ. Paris-Sud, Inserm, Équipe d'Épidémiologie respiratoire intégrative, CESP, 94807, Villejuif, Île-de-France, France
| | - Rachel Nadif
- Université Paris-Saclay, UVSQ, Univ. Paris-Sud, Inserm, Équipe d'Épidémiologie respiratoire intégrative, CESP, 94807, Villejuif, Île-de-France, France
| | - Orianne Dumas
- Université Paris-Saclay, UVSQ, Univ. Paris-Sud, Inserm, Équipe d'Épidémiologie respiratoire intégrative, CESP, 94807, Villejuif, Île-de-France, France
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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: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Dumas O, Varraso R, Boggs KM, Quinot C, Zock JP, Henneberger PK, Speizer FE, Le Moual N, Camargo CA. Association of Occupational Exposure to Disinfectants With Incidence of Chronic Obstructive Pulmonary Disease Among US Female Nurses. JAMA Netw Open 2019; 2:e1913563. [PMID: 31626315 PMCID: PMC6813668 DOI: 10.1001/jamanetworkopen.2019.13563] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
IMPORTANCE Exposure to disinfectants in health care workers has been associated with respiratory health outcomes, including asthma. Despite the biological plausibility of an association between disinfectants (irritant chemicals) and risk of chronic obstructive pulmonary disease (COPD), available data are sparse. OBJECTIVE To investigate the association between exposure to disinfectants and COPD incidence in a large cohort of US female nurses. DESIGN, SETTING, AND PARTICIPANTS The Nurses' Health Study II is a US prospective cohort study of 116 429 female registered nurses from 14 US states who were enrolled in 1989 and followed up through questionnaires every 2 years since. The present study included women who were still in a nursing job and had no history of COPD in 2009, and used data from the 2009 through 2015 questionnaires. Clean and complete data used for this analysis were available in July 2018, and analyses were conducted from September 2018 through August 2019. EXPOSURES Occupational exposure to disinfectants, evaluated by questionnaire and a job-task-exposure matrix (JTEM). MAIN OUTCOMES AND MEASURES Incident physician-diagnosed COPD evaluated by questionnaire. RESULTS Among the 73 262 women included in the analyses, mean (SD) age at baseline was 54.7 (4.6) years and 70 311 (96.0%) were white, 1235 (1.7%) black, and 1716 (2.3%) other; and 1345 (1.8%) Hispanic, and 71 917 (98.2%) non-Hispanic. Based on 368 145 person-years of follow-up, 582 nurses reported incident physician-diagnosed COPD. Weekly use of disinfectants to clean surfaces only (16 786 [22.9%] of participants exposed) and to clean medical instruments (13 899 [19.0%] exposed) was associated with COPD incidence, with adjusted hazard ratios of 1.38 (95% CI, 1.13-1.68) for cleaning surfaces only and 1.31 (95% CI, 1.07-1.61) for cleaning medical instruments after adjustment for age, smoking (pack-years), race, ethnicity, and body mass index. High-level exposure, evaluated by the JTEM, to several specific disinfectants (ie, glutaraldehyde, bleach, hydrogen peroxide, alcohol, and quaternary ammonium compounds) was significantly associated with COPD incidence, with adjusted hazard ratios ranging from 1.25 (95% CI, 1.04-1.51) to 1.36 (95% CI, 1.13-1.64). Associations were not modified by smoking or asthma status (P for interaction > .15). CONCLUSIONS AND RELEVANCE These longitudinal results suggest that regular use of chemical disinfectants among nurses may be a risk factor for developing COPD. If future studies confirm these results, exposure-reduction strategies that are compatible with infection control in health care settings should be developed.
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Affiliation(s)
- Orianne Dumas
- INSERM U1168, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, F-94807, Villejuif, France
- University de Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
| | - Raphaëlle Varraso
- INSERM U1168, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, F-94807, Villejuif, France
- University de Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
| | - Krislyn M. Boggs
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Catherine Quinot
- INSERM U1168, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, F-94807, Villejuif, France
- University de Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
| | - Jan-Paul Zock
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Paul K. Henneberger
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, West Virginia
| | - Frank E. Speizer
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Nicole Le Moual
- INSERM U1168, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, F-94807, Villejuif, France
- University de Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
| | - Carlos A. Camargo
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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8
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Quinot C, Amsellem-Dubourget S, Temam S, Sevin E, Barreto C, Tackin A, Félicité J, Lyon-Caen S, Siroux V, Girard R, Descatha A, Le Moual N, Dumas O. Development of a bar code-based exposure assessment method to evaluate occupational exposure to disinfectants and cleaning products: a pilot study. Occup Environ Med 2018; 75:668-674. [PMID: 29760172 DOI: 10.1136/oemed-2017-104793] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 02/27/2018] [Accepted: 04/21/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Healthcare workers are highly exposed to various types of disinfectants and cleaning products. Assessment of exposure to these products remains a challenge. We aimed to investigate the feasibility of a method, based on a smartphone application and bar codes, to improve occupational exposure assessment among hospital/cleaning workers in epidemiological studies. METHODS A database of disinfectants and cleaning products used in French hospitals, including their names, bar codes and composition, was developed using several sources: ProdHyBase (a database of disinfectants managed by hospital hygiene experts), and specific regulatory agencies and industrial websites. A smartphone application has been created to scan bar codes of products and fill a short questionnaire. The application was tested in a French hospital. The ease of use and the ability to record information through this new approach were estimated. RESULTS The method was tested in a French hospital (7 units, 14 participants). Through the application, 126 records (one record referred to one product entered by one participant/unit) were registered, majority of which were liquids (55.5%) or sprays (23.8%); 20.6% were used to clean surfaces and 15.9% to clean toilets. Workers used mostly products with alcohol and quaternary ammonium compounds (>90% with weekly use), followed by hypochlorite bleach and hydrogen peroxide (28.6%). For most records, information was available on the name (93.7%) and bar code (77.0%). Information on product compounds was available for all products and recorded in the database. CONCLUSION This innovative and easy-to-use method could help to improve the assessment of occupational exposure to disinfectants/cleaning products in epidemiological studies.
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Affiliation(s)
- Catherine Quinot
- INSERM, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, U1168, F-94807, Villejuif, France.,UVSQ, UMR-S 1168, University Versailles St-Quentin-en-Yvelines, F-78180, Montigny le Bretonneux, France
| | | | - Sofia Temam
- INSERM, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, U1168, F-94807, Villejuif, France.,UVSQ, UMR-S 1168, University Versailles St-Quentin-en-Yvelines, F-78180, Montigny le Bretonneux, France.,Faculty of Medicine, University Paris-Sud, Le Kremlin-Bicêtre, France
| | | | - Christine Barreto
- ProdHyBase, CClin Sud-Est, Saint-Genis-Laval, France.,ProdHyBase, Unit of Hygiene and Epidemiology, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Arzu Tackin
- AP-HP UVSQ, Equipe opérationnelle d'hygiène hospitalière, University Hospital of Poincaré, Garches, France
| | | | - Sarah Lyon-Caen
- INSERM, CNRS, Université Grenoble Alpes, U1209, Institute for Advanced Biosciences (IAB), Team of Environmental Epidemiology Applied to Reproduction and Respiratory Health, Grenoble (La Tronche), France
| | - Valérie Siroux
- INSERM, CNRS, Université Grenoble Alpes, U1209, Institute for Advanced Biosciences (IAB), Team of Environmental Epidemiology Applied to Reproduction and Respiratory Health, Grenoble (La Tronche), France
| | - Raphaële Girard
- ProdHyBase, Unit of Hygiene and Epidemiology, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Alexis Descatha
- INSERM, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, U1168, F-94807, Villejuif, France.,UVSQ, UMR-S 1168, University Versailles St-Quentin-en-Yvelines, F-78180, Montigny le Bretonneux, France.,AP-HP UVSQ, Occupational Health Unit/Population-Based Epidemiological Cohorts Unit, UMS 011, University Hospital of Poincaré, Garches, France
| | - Nicole Le Moual
- INSERM, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, U1168, F-94807, Villejuif, France.,UVSQ, UMR-S 1168, University Versailles St-Quentin-en-Yvelines, F-78180, Montigny le Bretonneux, France
| | - Orianne Dumas
- INSERM, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, U1168, F-94807, Villejuif, France.,UVSQ, UMR-S 1168, University Versailles St-Quentin-en-Yvelines, F-78180, Montigny le Bretonneux, France
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9
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Dumas O, Varraso R, Boggs KM, Descatha A, Henneberger PK, Quinot C, Speizer FE, Zock JP, Le Moual N, Camargo CA. Association of hand and arm disinfection with asthma control in US nurses. Occup Environ Med 2018; 75:378-381. [PMID: 29475850 PMCID: PMC5899017 DOI: 10.1136/oemed-2017-104740] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 01/23/2018] [Accepted: 02/04/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To investigate the association between occupational exposure to disinfectants/antiseptics used for hand hygiene and asthma control in nurses. METHODS In 2014, we invited female nurses with asthma drawn from the Nurses' Health Study II to complete two supplemental questionnaires on their occupation and asthma (cross-sectional study, response rate: 80%). Among 4055 nurses (mean age: 59 years) with physician-diagnosed asthma and asthma medication use in the past year, we examined asthma control, as defined by the Asthma Control Test (ACT). Nurses were asked about the daily frequency of hand hygiene tasks: 'wash/scrub hands with disinfectants/hand sanitizers' (hand hygiene) and 'wash/scrub arms with disinfecting products' (surrogate of surgical hand/arm antisepsis). Analyses were adjusted for age, race, ethnicity, smoking status and body mass index. RESULTS Nurses with partly controlled asthma (ACT: 20-24, 50%) and poorly controlled asthma (ACT ≤19, 18%) were compared with nurses with controlled asthma (ACT=25, 32%). In separate models, both hand and arm hygiene were associated with poorly controlled asthma. After mutual adjustment, only arm hygiene was associated with poorly controlled asthma: OR (95% CI) for <1 time/day, 1.38 (1.06 to 1.80); ≥1 time/day, 1.96 (1.52 to 2.51), versus never. We observed a consistent dose-response relationship between frequency of arm hygiene tasks (never to >10 times/day) and poor asthma control. Associations persisted after further adjustment for surfaces/instruments disinfection tasks. CONCLUSIONS Frequency of hand/arm hygiene tasks in nurses was associated with poor asthma control. The results suggest an adverse effect of products used for surgical hand/arm antisepsis. This potential new occupational risk factor for asthma warrants further study.
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Affiliation(s)
- Orianne Dumas
- INSERM, U1168, VIMA: Aging and chronic diseases. Epidemiological and public health approaches, F-94807, Villejuif, France
- Univ Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
| | - Raphaëlle Varraso
- INSERM, U1168, VIMA: Aging and chronic diseases. Epidemiological and public health approaches, F-94807, Villejuif, France
- Univ Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
| | - Krislyn M Boggs
- Channing Division of Network Medicine, Department of Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Alexis Descatha
- INSERM, U1168, VIMA: Aging and chronic diseases. Epidemiological and public health approaches, F-94807, Villejuif, France
- Univ Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
- AP-HP UVSQ, Occupational Health Unit/Population-Based Epidemiological Cohorts Unit, UMS 011, University Hospital of Poincaré, Garches, France
| | - Paul K Henneberger
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, WV, USA
| | - Catherine Quinot
- INSERM, U1168, VIMA: Aging and chronic diseases. Epidemiological and public health approaches, F-94807, Villejuif, France
- Univ Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
| | - Frank E Speizer
- Channing Division of Network Medicine, Department of Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jan-Paul Zock
- ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Nicole Le Moual
- INSERM, U1168, VIMA: Aging and chronic diseases. Epidemiological and public health approaches, F-94807, Villejuif, France
- Univ Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
| | - Carlos A Camargo
- Channing Division of Network Medicine, Department of Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, USA
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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10
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Dumas O, Wiley AS, Quinot C, Varraso R, Zock JP, Henneberger PK, Speizer FE, Le Moual N, Camargo CA. Occupational exposure to disinfectants and asthma control in US nurses. Eur Respir J 2017; 50:50/4/1700237. [PMID: 28982772 DOI: 10.1183/13993003.00237-2017] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 07/15/2017] [Indexed: 11/05/2022]
Abstract
Disinfectant use has been associated with adverse respiratory effects among healthcare workers. However, the specific harmful agents have not been elucidated. We examined the association between occupational exposure to disinfectants and asthma control in the Nurses' Health Study II, a large cohort of female nurses.Nurses with asthma were invited in 2014 to complete two questionnaires on their current occupation and asthma (response rate 80%). Asthma control was defined by the Asthma Control Test (ACT). Exposure to major disinfectants was evaluated by a job-task-exposure matrix (JTEM).Analyses included 4102 nurses with asthma (mean age 58 years). Asthma control was poor (ACT score 16-19) in 12% of nurses and very poor (ACT score ≤15) in 6% of nurses. Use of disinfectants to clean medical instruments (19% exposed) was associated with poorly (OR 1.37; 95% CI 1.05-1.79) and very poorly (OR 1.88, 95% CI 1.38-2.56) controlled asthma (ptrend=0.004, after adjustment for potential confounders). Using JTEM estimates, exposure to formaldehyde, glutaraldehyde, hypochlorite bleach, hydrogen peroxide and enzymatic cleaners was associated with poor asthma control (all ptrend<0.05); exposure to quaternary ammonium compounds and alcohol was not.Use of several disinfectants was associated with poor asthma control. Our findings suggest targets for future efforts to prevent worsening of asthma control in healthcare workers.
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Affiliation(s)
- Orianne Dumas
- INSERM U1168, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, Villejuif, France .,Université Versailles St-Quentin-en-Yvelines, UMRS 1168, Montigny le Bretonneux, France
| | - Aleta S Wiley
- Channing Division of Network Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Catherine Quinot
- INSERM U1168, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, Villejuif, France.,Université Versailles St-Quentin-en-Yvelines, UMRS 1168, Montigny le Bretonneux, France
| | - Raphaëlle Varraso
- INSERM U1168, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, Villejuif, France.,Université Versailles St-Quentin-en-Yvelines, UMRS 1168, Montigny le Bretonneux, France
| | - Jan-Paul Zock
- ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain.,Universitat Pompeu Fabra (UPF), Barcelona, Spain.,CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Paul K Henneberger
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, WV, USA
| | - Frank E Speizer
- Channing Division of Network Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Nicole Le Moual
- INSERM U1168, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, Villejuif, France.,Université Versailles St-Quentin-en-Yvelines, UMRS 1168, Montigny le Bretonneux, France
| | - Carlos A Camargo
- Channing Division of Network Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Dept of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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11
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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